NMHC Advice-on-Innovative-Technologies-in-eMental-Health

Abstract

The National Mental Health Commission report explores the use of new and emerging technologies and how this might create revolutionary change in the mental health system.

Full text

Advice on
Innovative
Technologies in
e-Mental Health
Briefing Paper for the National Mental Health Commission
Associate Professor Jane Burns
George Liacos
Felicity Green
In consultation with:
Dawn O’Neil AM
Anil Thapliyal
October 2014
Young and Well CRC
Unit 17, 71 Victoria Crescent
Abbotsford VIC 3067 Australia
youngandwellcrc.org.au

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Advice on Innovative Technologies
in e-Mental Health
Briefing Paper for the National Mental Health Commission
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Young and Well Cooperative Research Centre
The Young and Well Cooperative Research
Centre is an Australian-based, international
research centre that unites young people with
researchers, practitioners, innovators and policy-
makers from more than 70 partner organisations.
Together, we explore the role of technology in
young people’s lives, and how it can be used to
improve the mental health and wellbeing of young
people aged 12 to 25. The Young and Well CRC
is established under the Australian Government’s
Cooperative Research Centres Program.
youngandwellcrc.org.au
Spark Strategy
Spark Strategy is an agency for strategic thinking,
transformation and sustained action. Consulting
to public, private and not-for-profit organisations,
Spark strives for sector reform through the
development and implementation of innovative
business models. Mental health has comprised
the majority of Spark’s portfolio for a number of
years, and the organisation currently advises a
range of stakeholders in this area, including
funding bodies, research organisations, services
providers and Governments, both in Australia and
internationally.
sparkstrategy.com.au
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Biographies
ASSOCIATE PROFESSOR JANE BURNS
Jane is the founder and CEO of the Young and Well Cooperative Research Centre. Its establishment is a
culmination of Jane’s work in suicide and depression prevention over the last two decades which has focused on
international and national partnerships with academic, government, corporate, philanthropic, not-for-profit and
community sectors. She holds a Principal Research Fellowship at Orygen Youth Health Research, was a
VicHealth Principal Research Fellow and a Commonwealth Fund Harkness Fellow at the University of California,
San Francisco. She holds a PhD in Medicine from the Faculty of Medicine (Public Health and Epidemiology)
University of Adelaide. Jane was a Victorian Finalist in the 2012 Telstra Business Women's Awards and was
listed in the Financial Review and Westpac Group 100 Women of Influence in 2012.
GEORGE LIACOS
George has advised government, not-for-profit and commercial organisations for over 17 years in the areas of
new business and funding models, business and digital strategy, and system transformation. Prior to this he grew
and sold a $100 million private sector business; meaning he brings a strong practicality and commerciality to his
strategic advice. His experience across a combination of sectors including digital, strategic business models and
commercial experience means his advice is specialist, practical and executable. Prior roles have seen George as
the National Lead Partner for Transformation at Grant Thornton, Program Director for the Department of Premier
and Cabinet as well as Chairman and Non-Executive Director on a number of technology and service businesses.
FELICITY GREEN
Motivated by unearthing unconventional methods of funding, Felicity works with a number of not-for-profit and
government stakeholders to develop new models for sustainability. Areas of expertise include commercialisation,
ideation stress testing and execution planning. Felicity brings an international perspective to her work, as a result
of her work experience and her MBA studies at Peking University. Her work in the mental health field is extensive,
ranging from strategy development to process improvement and retained commercial advisory services.
DAWN O’NEIL AM
Dawn has sat on both not-for-profit, community and public sector advisory boards for over 20 years where she
has contributed to social and health policy, senate inquiries and think tanks. Dawn takes a wide view and has
highly developed strategic skills with strong governance, strategic and organisational development and change
management background. As a CEO, Dawn was known as a collaborative, visionary and strategic thinker not only
within Lifeline and beyondblue but more broadly contributing to not-for-profit, mental health and suicide prevention
reform in a rapidly changing world. Most recently Dawn has led the development of the first Strategic Plan for the
new National Mental Health Commission and has recently undertaken a study tour for the Centre for Social
Impact into how the Collective Impact Framework could be implemented in Australia to increase the social impact
of the social sector and is Chair of the innovative social enterprise STREAT.
ANIL THAPLIYAL
Anil has a passion for improving people’s health and wellbeing through the application of information
communication technology integrated within people’s care in a seamless way. His work is at the interface of the
public and private sectors and his career has focused on making tangible improvements in the e-Mental Health
and Addictions sector. Based on his longstanding work with the NZ National Depression Initiative, he decided to
focus on the broader e-Mental Health and Addictions domain. He is widely regarded as a leader in the
implementation and integration of e-Mental Health and Addiction programs in the Public and Primary Healthcare
services. He has also led the development of many key pieces of e-Mental Health strategy.

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Table of Contents
Executive Summary……………………………………..…………………..…………………..…………….… 5
Introduction……………………………………………………………………………………….………………. 16
1. Innovative technology and funding models………………………………………………………………... 18
2. The current e-mental health landscape…………………………………………………………………….. 35
3. Cognitive behaviour therapy………………………………………………………………………………….. 54
4. Telehealth, telephone helplines and websites…………..………………………..………………………… 60
5. Local initiatives…………..………………………..………………………..……………….…..……………... 66
6. Potential gaps in e-mental health services in Australia……..………………..………………………..….. 70
7. E-mental health records…………..………………………..………………………….……………………… 76
8. Appendices…………..………………………..………………………..………………………..…………….. 79
References……………..……………..……………..……………..………..…………….……..……………... 122

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Executive Summary
There is a very strong evidence base supporting the
role of technologies and the effectiveness and cost-
effectiveness of e-mental health solutions, and yet
that evidence is not necessarily translated to
practice and policy.
The nature and volume of demand for care has
moved well beyond any argument that face-to-face
clinical systems alone are the answer. Universal
access to high quality care is a promise unkept, with
the remote, rural and vulnerable often unable to
access resources, care and support.
Due to piecemeal funding, sector uncertainty and a
lack of a coordinated strategy, strong supported
leadership with a focus on cooperation, and
exploiting the opportunity that is e-mental health,
and its role in the broader system of care, has been
lacking. This has led to uncoordinated development
and unacceptable levels of duplication and waste.
Compounding this, the increasingly competitive
funding landscape has led to an introspective focus
on differentiation through online brand promotion
and the dissemination of many narrowly focused e-
products. Many of these are not built on evidence
and do not interoperate to provide individuals with a
seamless care experience.
Further, the economic and social costs of system
failure (some of which is avoidable in an integrated
model) mean that the future unchanged is one of a
continual leakage of funds, social exclusion and
economic opportunity cost. Demand for services
already exceeds supply and is continuing to grow.
Broadly, the e-mental health sector is united and
agrees that it is time to rationalise and coordinate.
Technologies are available that can build an
integrated system of care that entwines both the
electronic and face-to-face modes of mental health
care, and fuses them both to broader health care.
It is time to rethink what behaviours funding models
should encourage. This is less about competition
and more about cooperation and a sector re-tasking
its efforts towards exploiting the digital opportunity.
A more united sector could create a trusted super
highway – leveraging the NBN – that guides and
fast-tracks new, evidence-based, interventions in
reaching those that need them, when they need
them.
Accelerated research and development; the
embedding of evaluation, translation and utilisation;
the development of common and shared standards
that promote interoperability; the shift towards
impact assessment and measurement; and big data
capture and use, are all components that will
coalesce e-mental health solutions and integrate
them with clinical care into a sustainable model.
The system reimagined is reoriented around the
individual. It enshrines self-managed care,
individually controlled data, and mass customisation
to deliver a seamless pathway to the appropriate
care for each person.
Fortunately for Australia, significant contributions to
date have meant that the system reimagined is
within our reach. Many of the building blocks exist
and need to be coordinated. Where there are gaps,
the sector is moving towards partnerships with
consumers and stakeholders to design interventions
to fill these gaps.
Additionally, the advent of digital business models
provide a level of funding granularity that, when
combined with other funding models, make what
was previously unfeasible, distinctly possible.
Below are six recommendations that support the 25
sub-recommendations from each chapter that will
see the realisation of a system reimagined.

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MAJOR RECOMMENDATIONS
A 10-year roadmap has been set which ambitiously argues that e-mental health should be considered not just as a
complement to face-to-face services, but rather as a means of: a) reducing complexity; b) removing inefficiency; c)
promoting accountability and measuring effectiveness; d) providing consumer choice; and e) reducing disparities in
access to care.
Integration of e-mental health with face-to-face services would, in one stroke, satisfy three strategic objectives:
1. Enable effective performance assessment and governance through the provision of accurate and timely impact data.
2. Inform better, more targeted policy that has practical and translational implications for service providers.
3. Act to optimise the government’s expenditure, reduce duplication and drive self-management to ensure that
everyone gets the right help at the right time.
In order for there to be effective performance metrics and governance, reliable and timely data on system performance
must be collected. An integrated system, underpinned by e-mental health ecosystems, provides this reliable and timely
method for data collection. The e-mental health sector must be encouraged to embrace and unite in the use of such an
ecosystem, with a common and shared commitment to reducing duplication, working cooperatively towards improving
the mental health and wellbeing of all Australians.
In the same way that consumers choose combinations of apps for their mobile phones as opposed to installing large
pieces of software on their computer, the e-world is moving towards bite-sized interoperable components whose data is
dynamically aggregated into ‘report cards’ tailored for each person. This is a cost-effective and contemporary alternative
to monolithic, old architecture systems like the Personally Controlled Electronic Health Record (PCEHR). In line with this,
the Government prioritised funding for Project Synergy, with an expectation that it would, during piloting stage, showcase
interoperability. Synergy is focused specifically on young people but, if effective, could be deployed across all stages of
the lifespan.
This review argues that transactional record keeping systems like the PCEHR will do little to reduce the cost of mental
illness and improve the wellbeing of Australians. This review argues that the PCEHR has not considered the interests of
consumers, is still medically oriented, and fails to encourage the individual to own and use their own data in self-
managed care.
1. ‘Bricks and mortar’ solutions will never meet demand. The only feasible, cost-effective solution is to
deploy e-mental health to move beyond a treatment-focused medical model to one that directly
supports self-management. To achieve this, strong, decisive leadership and good governance in the
first two years is critical. The public and private sectors will commit at least $100 million to align,
consolidate and integrate the mental health system around the use of e-mental health technologies.
$50 million should be invested by Federal and State governments, and $50 million by the private sector across
Universities, Non-Government Organisations and Industry. Government adopting a seed funding approach will
enable the sector to unite and solve the current challenges together. This needs to happen immediately, and is
specifically for e-mental health and capability building within the sector. It does not include budget for
adjustments to the face-to-face system. It is recommended that this government funding for e-mental health be
done through offset where money is wasted (e.g. PCEHR), consolidation (e.g. Lifeline as the gateway service
for all telephone crisis support, consolidation of web-enabled chat and online counselling i.e. e-headspace and
Kids Helpline – see Figure 1) and reallocation, by ceasing to fund duplicative and inefficient services such as
mindhealthconnect.
2. In the first two years, explore opportunities to leverage new and emerging technologies to deploy a
universally available integrated system of care. An integrated system blends both online and offline
resources into a comprehensive and seamless experience for the individual. Deploying this system of care
would also include establishing the standards and interfaces for the seamless exchange of data between
system components (be they online or offline) so as to enable a ‘tell it once’ philosophy.

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3. In years 3 and 4, once strong leadership has been displayed by the e-mental health sector, redesign the
system of care using new and emerging technologies to re-orient the individual at the centre of the
system, as opposed to its current pivot of medical service provider. This approach is best articulated as ‘user-
centred design’. This would include deploying technology that enables individuals to control the sharing of their
data, and offers peer-to-peer and family support, enhanced self-management and customisable treatment
pathways. Currently, services like MoodGym, Beacon, THISWAYUP and MindSpot have a strong evidence
base but are not user-friendly. A major focus should be on user-centred design across demographics. A ‘one
size fits all’ approach will not address the issues of disparity and access to care.
4. Build on Australia’s leadership in R&D and leverage new and emerging technologies to enable
continuously developing integrated digital products and services that attract PPP (public/private/partner) sector
investment with a focus on a vibrant R&D pipeline (research optimisation, rapid prototyping, large scale
deployment) and an exploration of the export potential. Hubs of innovation in e-mental health exist across our
universities, however the only example of collaborative practice is in youth mental health with the establishment
of the Young and Well CRC, which has resulted in multi-disciplinary and cross-sector partnerships such as the
Online Wellbeing Centre, Link and the Mental Health Professionals Clinic. R&D innovation is critical to
reimagining the e-mental health system, but this must be positioned as partnership opportunities that explore
the translation of research to practice and policy, and that critically explores sustainable funding models,
including where appropriate commercialisation and licensing to other countries, and/or international cross-
country investment in innovation.
5. Fill the leadership vacuum. The sector is in need of strategic and transformational leadership across Public,
Private and Partners (mental health sector) if it is to stop squandering its decades of investment in e-mental
health, and seize the opportunity that new and emerging technologies present. This leadership needs to
champion user-centric integrated systems of care.
a. Establish an E-mental Health Research Centre Think Tank that builds on the investment of the
National Health & Medical Research Council (NHMRC), their Centres of Excellence and program
funding. This think tank would be resourced to bring together collective research knowledge across
University Centres – which aligns researchers, capitalises on NHMRC and Australian Research
Council (ARC) direction and informs policy;
b. Build on Project Synergy and create an Office of Digital Transformation in e-mental health
research that works in parallel with the Think Tank to enable, guide, assess and oversee the
realisation of this digital transformation and integration with face-to-face services, based on new and
emerging technologies. The Office would set direction across PPPs, manage stakeholders, fast-track
the shift towards user-centric design, and assume responsibility for implementing ‘backbone’
infrastructure that sits outside of any one organisation and is needed to support the ecosystem (e.g.
data plans, PBS subsidies, NBN concessions, funding changes);
c. Adopt a global leadership position to leverage local advances. This would include developing
funding links to global system and research funders, providers and philanthropists, as well as thought
leadership. The vast preponderance of its focus, however, should be on business and system
development activities so as to leverage new and emerging technologies and practices globally for
both scale and national benefit.
d. Create a reform blue print that builds on the e-mental health alliance strategy, for the digital
transformation of the sector and its participants so as to deliver a user-centric, integrated system of
care that maximises the opportunities provided by new and emerging technologies.
e. Develop an aggressive transition plan, with public/private/e-mental health partnership
implementation focus, and against which the PPP’s will be assessed and funded.

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f. Resource, support and nurture young and early career researchers and practitioners, and grow
emerging leaders in the field by encouraging them to think strategically about the transformative
potential of technology, and empower them to develop skills in business and strategic development
and user-centric design.
6. Reorganise and focus the sector
a. Implement a sector-led, collective impact, innovation and integration framework for research,
design, development and rollout of new interventions, integrations to other systems and closure of any
system gaps. Implementing the blueprint will require the collaboration of multiple experts and
organisations. Create a distribution framework model that divides e-mental health into six ‘components’
(Gateway and Information Services, Crisis, Web and Telephone Support, Telehealth and Therapist
Assisted Support, Online Self Directed Therapies (CBT, IPT etc.), Peer-to-Peer and Online Forums,
New and Emerging Technologies). Appoint a champion for each component who is funded, tasked and
assessed on their delivery of the e-mental health transition plan, innovation, and integration associated
with their component. It is envisaged that this would be delivered using a collective impact framework,
with these appointed component leaders acting as the backbone for a collective of specialist subject
matter experts in their component. Component leaders would be accountable to the overarching
transition framework.
b. Transform how the sector is funded through innovative business and funding models for
sustainability. Provide large-scale block funds for five years and then deploy models that leverage
government investment and share the burden of funding outside government alone. Develop capability
within the sector to be able to understand and innovate their business models, so that their funding
models ultimately transform into sustainable funding models within five years.
c. Give the sector transitional security whilst it undertakes the business model transformation. Provide
seed capital to enable both the capability building and the development of sustainable models, while
holding participants accountable for outcomes against this support through practical governance and
standards.
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A SYSTEM FRAGMENTED
While some steps have been taken towards
remediating and reforming Australian mental
health care, the current system remains
fragmented.
A variety of online mental health interventions and
mobile applications have been developed as an adjunct
to this system rather than as a key transformational
element for increased reach, access, and engagement.
Both the face-to-face and online models are fragmented
and operate separately.
At present, Australia lacks an ‘end-to-end’ system
design, with the mental health care landscape
populated by government, university and not-for-profit
organisations, but not appropriately integrated to
provide a streamlined pathway of care for the user.
The most common rationale for online support has been
an economic justification: it is cheaper to deliver
services online.
This review argues for a reframing of that rationale and
purports that an integrated service is optimal for mental
health outcomes. While there will always be a need for
face-to-face services for those who are severely unwell
and those with complex needs, best practice would
dictate this approach is supplemented by around-the-
clock support provided through technologies.
While technology can be used as an adjunct to clinical
care, it is becoming clear that there are a number of
conditions that can be effectively self-managed, and
that technology provides the perfect low-cost vehicle to
do this. In addition, because of its reach, the
incremental cost per person of receiving this care
reduces.
Australia has a universal health care system that aims
for equal care and access for all individuals. The reality
is that we currently have disparities in access to mental
health care, with those most vulnerable least likely to
receive evidence-based and timely services. In the field
of mental health, current thinking generally leads to
funding of face-to-face mental health service providers.
This, however, is not only financially unsustainable, but
in practice will never achieve the reach and impact
required to live up to the vision of universal care.
Services are being stretched, waiting lists are long and
clinician time is being spent on a disproportionate
number of cases that could be addressed through self-
managed and online modalities. As a result, those living
with a mental illness often receive sub-optimal
treatment.
For the purposes of this review, e-mental health is an
ecosystem of purpose built, digital tools (such as online
interventions, mobile apps, multimedia content, digital
campaigns, biometric devices, and so on), that
individuals and clinicians can organise into cohesive,
combinations, which meet specific needs of the
consumer in the way they want them met. It enables
information and services to reach those who are remote
or disadvantaged, like never before. At the heart of self-
managed care is respect for the individual and a
philosophy that blends mass customisation with
economic prudence so as to yield multiplied social
benefit.
It is important to note that e-mental health is not a
single large application or portal that individuals ‘log
into’. Past investments have focused on electronic
record keeping (Personally Controlled Electronic Health
Record) for efficiency purposes, or standalone solutions
(such as Telemedicine) for reach. Rather, we are
imagining an ecosystem of agile and mobile
technologies that bridge the digital divide, making the
most of small data plans and public internet access at
places such as libraries, cafés and hotspots.
Integrating digital technologies (for example, apps, data
warehouses and websites) with face-to-face care is not
a pathway to cost reduction, but rather to greater
accessibility and a more integrated and effective sector.
E-mental health should not be seen as a substitution for
face-to-face services, rather it is able to deliver greater
value through redistribution of demand.
Of even greater impact, however, will be its role in
empowering individuals with choice and enabling self-
management through early stages of illness to
recovery, and in doing so making space in the system
for those needing assistance.
In the field of mental health, current thinking
generally leads to funding of face-to-face and
mental health service providers. This,
however, is not only financially unsustainable,
but in practice will never achieve the reach
and impact required to live up to the vision of
universal care.

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EXISTING ONLINE RESOURCES: WORLD LEADERS YET
UNCOORDINATED AND DUPLICATED
The development and launch of new
technologies to address issues around mental
health and wellbeing is staggering. At the time
of writing there were over 100,000 apps
targeting health and wellbeing worldwide.
In Australia, a number of current providers offer a range
of e-mental health services from self-managed care
through to relapse prevention. The following list is by no
means exhaustive, however provides an introduction:
• beyondblue (accessed by 2.5 million unique users
per annum) and ReachOut.com (accessed by 1.5
million unique users per annum) provide health
promotion and some early intervention and
prevention activities (for example, SAFEMinds
online training for teachers and school staff at
youthbeyondblue.org; beyondblue 24-hour infoline
and ReachOutCentral.com).
• e-hub at the Australia National University
(accessed by 828,000 unique users per annum)
provides prevention and self-care in depression,
anxiety, social anxiety and facilitates peer-to-peer
support through BlueBoard, BluePages, Beacon
and MoodGym, the world’s first online CBT
program.
• Lifeline Australia and Kids Helpline provide online
and telephone counselling support. Lifeline helps
more than 674, 321 Australians with crisis support
services for suicide. eheadspace and Butterfly
Foundation provide web-enabled chat, and
Reachout.com have a facilitated chat room.
• Black Dog Institute (accessed by 1.25 million
unique users per annum) provides information,
prevention, self-care and telemedicine for mood
disorders.
• Mindhealthconnect (accessed by 100,000 users
per annum) provides an online portal to mental
health services.!
• Virtual clinics such the National eTherapy Centre,
MindSpot and VirtualClinic provide either
automated or clinician-guided services, or both.
Research is currently underway by the Young and
Well CRC to develop a University Clinic and an
online multidisciplinary e-mental health clinic.
• A range of models exist for the use of e-mental
health systems within general practice such as
Black Dog Institute.
• Innovative online communities have evolved such
as Hello Sunday Morning and internationally Big
White Wall and headspace.com.
There are also providers from the non-university or
public health sector, such as private psychologists and
psychiatrists who provide online therapy, and
increasingly insurers and the telecommunications
providers are exploring commercial opportunities for e-
mental health.
As they stand currently, these services do not achieve
the level of benefits that might be obtained in a united
and coordinated system of mental health care.
Significant investment has been made in start-up but
little resource is dedicated towards implementation.
Although these services promise to reduce demand on
the health workforce, the evidence for this has not been
established.
Key messages
1. There is no overarching design or picture of
how current services interact, or the role that
each should play.
2. There is no overarching guidance as to what
service gaps need filling, so organisations
build what they want, based on perceived
need, often with public funding.
3. There is no public register of what has been
publically funded or how effective it is. This is
one of the prime reasons for duplication and
waste.
4. There are no widely available quality or
accreditation standards to ensure consumers
are getting evidence-based online help.
5. There is no overarching technical framework
to guide interoperability between products, so
data is rarely shared and used in aggregate to
help individuals.
6. There are only a small number of locations
individuals can go to get advice about e-
mental health options, and there is little
incentive for professionals to use and
prescribe use of these interventions.

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A SYSTEM REIMAGINED
E-mental health is both a prerequisite for an
effective, universally accessible mental health
care system from this point forward, as well
as being a positive disrupter of the current
system with its many challenges.
As a fundamental enabler of access to information and
self-management, e-mental health by its very nature
conforms to the World Health Organisation (WHO)
views and acts to both build mental wellness and puts
the individual at the centre and control of their health
and wellbeing.
In short, the pathway to a comprehensive and
progressive model involves integrating on and offline
systems and developing standards and interoperability
between online offerings.
This will create a universally available, personalised
and empowered end user experience, with solutions
that scale to support an individual across their life and
no matter where they live. This will ultimately transition
Australia’s mental health landscape away from a patchy
programmatic approach without requiring entire system
reform.
E-mental health does not require system-changing
investment, but it does require intelligent investment
and coordination. There are well-funded, disruptive and
strong e-health ecosystems, involving some of the
world’s largest brands, already emerging from a number
of private and philanthropic funded sources. This
confirms that e-health and e-mental health are
inexorably moving away from being small scale ‘cottage
industries’.
There is a role for government to set the agenda, help
translate these developments into the mental health
field and help integrate the same into face-to-face
models.
There is a coordinative role for government to help build
the standards and interoperability frameworks that, if
adhered to, will enable new interventions to quickly be
deployed to meet need.
By directing, seed funding and maintaining this
translation and integration, the potential social and
economic return – particularly if done so under
sustainably designed funding models – will be
significant.
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E-mental health does not require
system-changing investment, but it
does require intelligent investment
and coordination.
The system re-imagined will:
1. Put the individual at the centre, enabling choice
and delivering a customised pathway for each
person’s needs. Further, it will enable self-
management of care as well as personal control
of who sees each individual’s data.
2. Be available to all individuals everywhere
when they need it.
3. Reallocate demand to the most cost effective
and appropriate modality for the need.
4. Work alongside and enhance face-to-face
services both in-between and during sessions.
5. Be an ecosystem rather than a portal, or
individual application. The ecosystem will be
interoperable enabling a ‘tell it once’ experience
for the individual.
6. Comprise components that are authorised,
based on evidence, accessibility and financial
sustainability.
7. Be developed and promoted by blending and
leveraging public funds with private and
philanthropic funds.
8. Be managed on a day-to-day basis along market
principles.
9. Ensure universal access with adjustments to the
Medicare Benefits Schedule (MBS) and other
means-tested assistance. Further incentives will
be aligned to desired service delivery and sector
behaviour.

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NEW AND EMERGING TECHNOLOGIES:
NOT IF OR WHEN, BUT WHICH ONE AND WHY
A focus on examining whole-of-life, whole-of-
population and the importance of self-
managed care.
There can no longer be any doubt about Australians’
use of technology and their adoption of new technology
alternatives. Eighty-six percent of Australians access
the internet daily, with 44 percent of Australians using
the internet more than five times a day.
Further, the vast majority of access is via smartphone
and mobile devices. With the NBN rollout, the falling
cost of data plans and the mainstreaming of more
internet-connected devices, the gap between those that
do and do not use technology daily is diminishing.
Some are simply a digitisation of existing processes or
services, others are innovative and enjoy rapid user
uptake.
Some innovative examples of emerging tech in e-
mental health include:
• myStrength: mystrength.com offers a range of
resources to improve mental health and overall
wellbeing.
• ThriveOn: thriveon.com offers personalised online
programs enhanced by professional ‘coaches’.
• Empower Interactive: empower-interactive.com
offers web and mobile behavioural health solutions
and teaches individuals specific coping skills for
managing stress, anxiety and depression through
an interactive e-learning application, ReThink,
offers access on mobile devices. Clinicians can
track clients’ progress as they use the program and
structure their sessions and highlight key issues.
• Bio and ambient data - SMS, social media posts,
location, heart beat, blood flow - to spot patterns
that indicate poor emotional state. These include
ginger.io (ginger.io), Biobeats (biobeats.com)
Argus Labs (arguslabs.be) and the Durkheim
Project with US veterans.
• Carepass (carepass.com) is a private sector
funded health portal that links apps into a wellness
plan.
• Open mHealth (openmhealth.org) offers non-profit
illness specific portals that link apps into a
treatment plan.
• TicTrac (tictrac.com) and its alliance with
Samsung, provides self-managing websites that
consolidate data from an individual’s many health
apps and biometric devices into one dashboard.
• Recently the Department of Health funded the
Young and Well CRC to begin development of such
common standards and data sharing interfaces via
Project Synergy.
Key Messages
1. Eighty-six percent of Australians access the
internet daily.
2. Society’s movement towards mobile computing
has enabled the transition from concept to
mainstream of the biometric device (such as
wristband, watch, glasses or chest strap formats,
however, recent products have seen biometric
sensors placed in shirt fabrics and digestible
wafers). All of these ‘smartech’ devices are
paired with software to retrieve the data and then
interpret it for the user.
3. Algorithms, data analytics and search results are
all being monitored so as to enable systems to
mass customise individual experiences and
predictively serve relevant content.
4. Apps and algorithms have evolved so as to
provide a person with real-time prompts and
suggestions for behaviour change in response to
changes in biometric feedback, social media
content or application usage patterns.
5. The next evolution of this domain is where
organisations are enabling data to flow between
apps and technologies or they are stringing
together sequences of apps and technologies
into a process flow, which is augmented by face-
to-face services.

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13
POTENTIAL FUNDING MODELS REQUIRED TO SUPPORT AN
INTEGRATED E-MENTAL HEALTH SYSTEM OF CARE
Depending solely on the public purse is not a
funding model. It is simply not sustainable.
Investment models (for example, public private
partnerships, innovative models such as social impact
bonds, and private sector risk-taking investment) are
unlocked and strengthened by evaluation. Effective
and robust evaluation of the impact of a particular
service or technology leads to an accurate assessment
of the social and economic return on investment of that
service or technology. It helps companies assess their
future income streams when considering investment in
technologies such as apps. It helps government assess
the payback of funding and make choices between
services and technologies. It helps consumers
understand which services and digital product
combinations deliver results. It helps service providers
build packages of services and digital products that
improve their effectiveness and reach.
Just as e-mental health is not a single platform or portal
(but rather an ecosystem of linked services and
technologies), ongoing e-mental health funding is not a
single monolithic model that covers all services and
digital tools.
E-mental health sustainability calls for the coordination
of smaller funding models that align to meet both the
interest of funders and the demands of consumers for
specific services and interventions. The challenge is to
ensure universal accessibility. Put another way, what is
needed is a level of granularity of funding that is based
on not only the individual, but also the individual’s
specific consumption and circumstances. The very
nature of digital technologies such as apps, mean that
e-mental health would be well placed to offer this
granularity as every interaction and transaction can be
tracked.
The Australian Government has already shown
leadership in the exploration of this space with an
investment in Project Synergy.
Further, there is a significant international movement
whereby health care insurers are reducing the cost of
care by using wellness treatments and tools. This is in
line with the now commonly accepted evidence that
investment in prevention has a disproportionately
positive impact in reducing an individual’s cost of care.
Given the factors outlined above, there are several
combinations of funding models that will deliver
sustainability and enhanced self-managed care.
There exist two special components of any funding that
should be maintained and expanded: Leveraged Funds
and tighter integration with the MBS.
• Leveraged Funds: Playing the role of correcting
market imperfections, there is a significant
opportunity to greatly expand and accelerate the
investment in, and integration of e-mental health in
Australia by the private sector, NGOs and
philanthropists matched with government funds. If
the sector invested wisely and created a model of
Social Return On Investment (SROI) and Economic
Return On Investment (EROI), we would see
models of sustainability extended. If articulation of
possible sustainable commercial models were
required of each applicant for these funds (as
discussed above) and drafted as a condition of the
funding, then these leveraged funds could be ‘re-
used’ for multiple purposes over time.
• MBS and PBS: In order to support universal
accessibility, whilst shifting the burden of funding,
the sustainable commercial models outlined should
be complimented with an enhancement of the MBS
and PBS to include coverage of e-mental health
interventions. Capping and cost containment
should be examined.
Key Messages
This paper proposes e-mental health funding models
based on:
1. Combinations of PPP’s, Social Impact Bonds,
matched and leveraged funds, and subsidies to
fund research and development.
2. A combination of micro-payments, transaction-
based subsidisation, health insurance premium
offsets, freemium models and monetisation of
digital assets (for example, access to de-
identified data) be deployed to fund ongoing
operations.
3. An evaluation-based mechanism that directly
links impact of the service or tool to funding
based on SROI/EROI principles. Further, that
this mechanism calls for regular reviews so as to
enable close measurement of effectiveness as
well as cater for the rapidly changing digital
landscape.

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14
A FUTURE VIEW OF THE E-MENTAL HEALTH LANDSCAPE
There are five core activities (outlined below) required to develop an ecosystem of e-mental health that interfaces with
face-to-face service offerings and that understand the intersection between mental health, health and other areas such
as housing, employment and social services. Principles that underpin this are integrated technology systems and user-
centric self-management, right through to clinical care. An example of how these could look is demonstrated in Figure 1:
1. Development of shared
technology platforms linked via
common standards and open
Application Programming
Interfaces (APIs);
2. Models of sustainable funding
that build on government
investment;
3. Innovation of existing and new
user-centric services using
emerging and new technologies;
4. Integration of e-mental health
interventions with face-to-face
mental health services across
states and territories;
5. Consideration of integration within
the broader health and other
contextual domains for example,
housing, employment, social
service, and so on.
Under this model, a spotlight is placed on the e-mental health domain so as to identify natural, divisible component parts.
It is suggested that these components are then assigned to expert ‘backbone’ organisations whose responsibility it is to:
1. Deliver parts of the blueprint and transition plan that relate to their component.
2. Utilise collective impact practices (Appendix 4), coordinate and support the activities of other domain experts to
deliver innovations and integrations for their components.
3. Provide policy and other advice with regards to their components.
4. Ensure collaboration with other e-mental health backbone organisations.
The spotlight has identified six major components of the e-mental health ecosystem:
1. Gateway and Information Services
2. Crisis, Web and Telephone Support
3. Telehealth and Therapist Assisted Support
4. Peer to Peer Support and Online Forums
5. Online Self Directed Therapies (Cognitive Behaviour Therapy (CBT), Interpersonal Psychotherapy (IPT), etc.)
6. Underpinning new and emerging technologies and cross-platform initiatives
Using the three filters of Capacity, Awareness and Reach, data from the sector online survey undertaken as part of
drafting this paper (and contained in Appendix 1) identified some candidate backbone organisations for each of the six
components.
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Figure 1: E-mental health innovation and integration

15
This picture does not provide a recommendation of which organisations should or, indeed, have an interest in becoming
backbone organisations. It merely illustrates a way of:
1. Segmenting the body of work to be undertaken to deliver a user-centric integrated system.
2. Aligning the expertise of the sector with the work required.
3. Coordinating sector participants in a collective impact approach so as to leverage impact and drive efficiency.
4. Reduce reform timelines by running the reform program along parallel, yet coordinated, streams.
The final slice of this diagram is at the centre alongside the underpinning and new and emerging technologies
component: funding. It is expected that the design of the funding component will be innovative and sophisticated and will
be coordinated out of the recommended new Office of Digital Transformation. It is not expected that the funding will come
solely from government. It is expected that funding will be linked to performance as either a backbone or supporting
organisation within each component.

!
16
Introduction
This paper consolidates evidence and recommendations from recent rapid reviews of e-mental health, both in Australia
and internationally. The primary documents included, “Strategies for adopting and strengthening e-mental health: a
review of the evidence” (Burns et al., 2014) and “E-mental health in Canada: Transforming the mental health system
using technology” (Mental Health Commission of Canada, 2014).
This paper also draws on a range of discussion papers created across the sector, such as, “Australia’s Mental Health
System: Can we achieve generational change?”(Medibank Health Solutions and Beyond Blue, 2013), “E-mental health: A
Rapid Review of the Literature”(Lal, 2014) and “E-mental health Services in Australia 2014: Current and
Future”(Christensen et al., 2014).
In addition to this material, a number of face-to-face and telephone interviews were conducted with government
departments and key industry leaders. An online survey supplemented the telephone interviews.
PROGRESSING THE CONVERSATION FROM ‘THE PROBLEM’ TO
‘THE SOLUTION’
The case for mental health reform has been made clear in numerous reports and academic publications. Australia
spends in excess of $28.6 billion per year to support people with a mental illness, equating to approximately 2.2 percent
of Australia’s Gross Domestic Product (Medibank Health Solutions and Nous Group, 2013).
The system is fraught with fragmentation and insufficient coordination, and supply is not meeting demand. Where the
current conversation falls short, however, is that in suggestions of system redesign, leveraging technology to develop
solutions to these problems is overlooked. This paper aims to demonstrate that, in fact, it is capitalising on these new
and emerging innovations and integrating them with each other and offline systems, which will deliver the greatest value
and most effective reform.
The recent Medibank and beyondblue publication (2014) proposed a reformed mental health system based on
complexity of need. This paper aims to build on this, by overlaying this concept with new and emerging technology
solutions, as a way of demonstrating ‘how’ to deliver the ‘what’.
As the amended diagram (Figure 2) on the following page demonstrates, different forms of e-mental health solutions
have the potential to address needs across the spectrum of mental health care and support, from mobile applications
and information websites to support the whole population in relation to the self management of wellbeing, through to self-
directed online interventions and web enabled chat for individuals with moderate needs, and by augmenting face-to-face
care to support complex needs. In this manner, e-mental health increases reach and frees up clinical treatment for those
with very complex needs, such as eating disorders, major depression and anxiety, drug and alcohol addictions and
psychoses.
The end game is that every Australian receives the right care, at the right time, in the right way.

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17
Figure 2: Building on the current thinking by outlining the role of e-mental health in system reform

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18
1. Innovative technology and funding models
!
This chapter provides a brief overview of current, emerging and potential technologies and funding models that have the
ability to transform the e-mental health landscape.
1.1 CURRENT, EMERGING AND POTENTIAL TECHNOLOGIES
Below is a diagram of the range of types of new and emerging technologies considered in this section. The body of this
report goes on to discuss components of this landscape as they relate to the development of a user centric, integrated
system of care.
Figure 3: New and emerging technologies in e-mental health
a) Mobile applications
A mobile application or “app” is a software application that is developed specifically for use on smartphones, tablet or
other portable devices, rather than desktop or laptop computers. Apps are available through online application
distribution platforms such as the Apple App Store, Google Play or BlackBerry App World.
Apps are generally small, individual software units with limited functionality, although their specificity has now become
part of their desirability. They allow consumers to handpick and customise what their devices are able to do. In e-mental
health a key challenge is in balancing evidence-based approaches with user experience characteristics. Smiling Mind is
an app that exemplifies this challenge, as it is very popular (high User Experience (“UX”) ratings) and evidence-informed
but currently lacks an evidence base of effectiveness (although it is currently subject to a Randomised Controlled Trial
(RCT) funded by the Young and Well CRC and supported by Queensland University of Technology).

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19
“59 percent of
Australians actively use
a mobile application at
least once a month.”
(Nielson, 2013)
GROWTH OF MOBILE APPLICATIONS
The use of smartphones to both access the internet and mobile applications
continues to grow exponentially. Between 2013 and 2014 the global use of
smartphones increased by 406 million people globally, reaching 1.82 billion devices
(up five percent in a year), with internet usage via mobile devices having increased
by 81 percent between 2012 and 2013 (Cisco, 2013). Australia is at the forefront of
this growing demand, and as at June 2013, over 11 million Australians owned a
smartphone and 7.5 million were accessing the internet through their device on at
least a monthly basis (ACMA, 2013).
Aligned to the growing use of mobile phones to access the internet, is the rapid
ascendance in the development and use of mobile apps. As of the end of 2012,
there were over 1.2 billion people using mobile apps, with this estimated to
increase to over 4.4 billion users by 2017 (Portio, 2013). This growth is enabled
through an ever-expanding number of available mobile apps, ubiquitous
distribution channels (for example, Apple Store and Google Play, each having
over 1.2 million apps available for download as of June 2014 (Informit, 2014), and
the emergence of Freemium business models (which now accounts for over 98 percent of app pricing models) available
to enable zero cost barrier to purchase (Gordon, 2013).
The mobile application market is fiercely competitive and has been polarised by the dominance of a few marketplaces.
The two biggest providers, Apple Store and Google Play, have had over 75 million and 80 million applications
downloaded, respectively from their stores since they have opened, accounting for over 90 percent of the global mobile
application market (Informit, 2014).
Apple (iOS)
•There are currently 500 million active devices
globally
•Despite Apple sitting behind Google Android with
over 75 billion app downloads, Apple App store
takes in over US$5.1 million a day, compared with
Google’s US$1.1 million
•42 percent of Australia’s 16 million smartphone
market
Google (Android)
•By the start of 2015, Android will have nearly
three billion active devices worldwide
•With over 80 billion apps downloaded to date,
the Google Android market is tracking 45
percent ahead of Apple App store downloads
•51 percent of Australia’s 16 million smartphone
market
“The number of mobile-
connected devices will
exceed the world’s
population by the end of
2014.” (Cisco, 2013)

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20
ROLE OF MOBILE APPLICATIONS IN MENTAL HEATLH AND WELLBEING
Riding the wave of app growth, health and wellbeing applications have boomed in this marketplace with everything from
running trackers to cognitive behaviour therapies now available through a mobile application. There are currently over
100,000 health and wellbeing related apps publicly available (Hides, 2014) with the market expected to be worth US$26
billion by 2017 (Week, 2013).
Many of these apps relate to diet, exercise and physical health monitoring, however, the growth in mental health
applications is both a concern and an opportunity within the healthcare profession.
The key reason for concern is that a number of studies have highlighted the poor quality of health and mental health
apps in terms of engagement, usability and functionality (Hides, 2014). There is also typically little information available
on app safety or effectiveness, beyond ‘star’ ratings and consumer reviews. While consumer reviews are important in
relation to engagement, trust and ‘word of mouth’ promotion, the selection of apps on the basis of popularity yields little
or no meaningful information on their quality or evidence based effectiveness (Fiordelli, 2013). In addition to this, many of
the mental health applications are not based on psychological theories or evidence-based practice (Fiordelli, 2013).
Despite these potential concerns, there are also a number of opportunities as research seeks to catch up with the
changes in technology. Although, there is still very little research in respect of suicide prevention apps, a number of
studies on web-based psychological interventions show this modality is popular with users, is cost-effective and can be
clinically efficacious (Proudfoot et al., 2013a).
Mobile technology offers a new dynamic to web-based treatments one of which is
the fact they are generally carried around by a person on a day-to-day basis
(Proudfoot et al., 2013a). A recent study undertaken by Judy Proudfoot et al. (2103)
from Black Dog Institute, on the impact of mobile phone and web program on
functional outcomes for people with mild to moderate mental health issues found
that these interventions brought about rapid improvements in mental health
symptoms and in work and social functioning. These results demonstrate that
delivery of CBT using a combination of both mobile phone and computer
technology is effective and acceptable to users.
Figure 4: Percentage of mHealth Apps by Category: iPhone & Android (Verasoni
Worldwide, 2012)
“76 percent of the general
public would find ‘Mobile
Health’ acceptable for
mental health monitoring
and self-management.”
(Donker T, 2013)

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21
b) Wearables and biometric devices
A "biometric device" is any device that measures a biological function or trait. Also called “wearable
computing”, these devices tend to operate in one of two main ways; verification or identification and they
can provide important baseline data on heart rate, sleep, brain function and blood glucose levels. This data is extremely
useful for e-mental health because it can monitor and demonstrate the important relationships between certain variables
such as exercise and eating behaviours through to the effects that this has on how individuals sleep and how they feel.
Innovations such as Google Glass, as well as apps that monitor activities, physiology, and habits provide sophisticated,
often real-time data, to both the patient and clinicians about important outcomes. These can range from simple
physiological measures such as weight; sleep patterns or electrocardiograms, to the measurement of habits such as diet.
Other examples include the measurement of exercise and daily recording of mood. In the field of geriatric health care
some centres now equip people with dementia with electronic tags that activate an alarm if they leave the premises.
Some examples of biometric devices currently being trialled in the e-mental health sector by the Young and Well CRC
and Brain and Mind Research Institute are UP by Jawbone, which has been used to track sleep patterns against
depression in teenagers and Fitbit, which has a personal health focus.
c) Gaming
Gaming has been proven as effective way to learn, and it is now being used to teach cognitive
behavioural skills to people with mental health problems and illness. An example of this is Reach Out
Central, a world first game based on principles of Cognitive Behavioural Therapy (Burns et al., 2010) and Sparx
(sparx.org.nz), a game based on an imaginary island where participants go on a quest and have to fight negative
automatic thoughts (NATs), and overcome problems to progress. The game, aimed at teenagers, has been shown in a
randomised controlled trial to be as effective as usual care in young people with mild to moderate depression.
Gamification is best defined as the use of game design elements in non-game contexts (Deterding, 2011). The game
design elements that have been successfully applied in other areas include points, achievements or badges,
leaderboards, levels, story integration, goals and associated feedback, rewards and progress indicators. Gamification is
used where the goal is to create greater engagement, motivation or fun among users of a tool or interface. There is
emerging evidence that some kinds of gamification (for example, simple rewards, point systems and badges) are useful
for short-term goals, that is, on-boarding or adoption, it may be that they are less useful in the long-term and where the
goal is to create deeper engagement with the content area.
Nicholson (2012) proposes that meaningful engagement and
long-term motivation is more likely to result through the use of
other types of gamification, such as, incorporating play in the
form of freedom to explore within boundaries, building in
exposition in terms of stories that are integrated with real world
settings, giving players choice within the system, providing
information using game design and display concepts, engaging
players with others interested in the real world setting and
helping players to reflect. (Nicholson, 2012)
In recent years, gamification has been successfully applied as a design concept to enhance user experience and
engagement in a variety of industries and domains including productivity, finance, health, education, sustainability, news
and entertainment media (Deterding, 2011), as well as by sport equipment manufacturers, coffee shops or in frequent
flyer programs (Bunchball, 2013). A number of recent studies have shown benefits of gamification for men’s physical and
mental health and wellbeing (Ahola et al., 2013). Gartner Research forecasts that by 2014, 70 percent of Global 2000
businesses will have ‘gamified’ elements in their services (Gartner Research, 2011).
The Young and Well CRC support a Gaming Research Group, led by Associate Professor Daniel Johnson from QUT,
with representation from universities across Australia and Johns Hopkins University:
http://www.youngandwellcrc.org.au/research/safe-supportive/gaming-research-group/.
“From the results, it appears that more
successful applications employ game-like
strategies or feature a playful design, which
challenges the commonplace notion that a
playful attitude is out of place in relation with
depression and mental health in general.”
(Rao, 2013).

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d) Social networking services
A social networking service is a platform that enables individuals or businesses to build social networks
and relationships between people who share common interests, activities, backgrounds and real-life
connections. Social networks are internet-based services that allow individuals to create a public profiles
and build a network of users with whom to share and view information. Social network sites are varied and they
incorporate new information and communication tools such as mobile connectivity, photo/video/sharing and blogging.
Popular platforms include Facebook, LinkedIn, Twitter, Pinterest and Instagram.
The main types of social networking services are those that allow the user to connect with friends (usually with self-
description pages) or business connections and to recommend and share engaging content. For this reason young
people in particular are high users of social networks. However, when framed in terms of e-mental health, they have
become another place where bullying can be prevalent because they have opened up private experiences and places to
the entire public.
Online peer support is the opportunity to seek and
obtain support from others facing similar problems.
The advantages of doing this online are the
opportunities to meet a significant number of
people and tap into crowd sourcing. Examples of
this in mental health includes the ReachOut.com
facilitated forum (Webb, Burns & Collin, 2007) and
Big White Wall (bigwhitewall.com), which is an
anonymous online service for people in
psychological distress. It offers support for self-
management of mental health issues, information,
and online therapy using a webcam, audio, or
instant messaging.
In 2013, the Hunter Institute and Mindframe partnered with the Young and Well CRC to bring the sector together to
discuss the role of Social Networking Services in Suicide Prevention. As a result several activities to support the sector
are being coordinated and Better Practice Guidelines have been created to support the sector in their use of new and
emerging technologies: http://reports.youngandwellcrc.org.au/a-better-practice-guide-for-services/.
e) Digital campaigns
E-mental health campaigns are typically aimed at raising
awareness, reducing stigma and promoting participation in
programs that promote positive social outcomes. Campaigns can reach
extremely high levels of awareness and engagement through utilising the
new pathways opened up by the opportunities of ‘digital’. That said, little
effort or resource is directed to understanding the impact of such
campaigns on behaviour change. Two examples of popular mental health
campaigns include Movember and beyondblue’s ‘Man Therapy’ initiative, which
encourages de-stigmatisation of men seeking help with depression. Given their
popularity it seems opportune that they could act as gateway platforms for
evidence-based interventions.
f) Online evidence-based interventions
Online evidence-based interventions can include web-based digital tools, community platforms and
programs. ‘Interventions’ encompass direct actions for treating mental health and also strengthening the
skills and capabilities of individuals to prevent the development of mental illness. The term ‘evidence-
based’ and what constitutes evidence for this paper is in some instances considered contentious. The ‘evidence base’
refers to existing evidence or research including epidemiological data, past evaluations, theories, strategies and models.
The evidence for online interventions is discussed in detail in Chapters 3 and 4.

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23
g) Big data
Big data refers to the use of large amounts of data to predict future behaviour and outcomes. This is
similar to the Amazon or Netflix model of using past buying behaviour to predict and offer the consumer
products that they will be likely to purchase. Examples in mental health include the use of data from individual health
providers on who responds to what treatment to predict what individual patients should be offered in the future. Another
is the use of predictive analytics to detect people at high risk of suicide. This involves examples such as monitoring social
media and other data to detect suicidal ‘signals’ and providing an intervention to prevent suicide. This approach is being
explored by Black Dog Institute and Brain and Mind Research Institute with the support of the Young and Well CRC.
h) Robots
Robots in mental health care have mainly been used in settings involving the care of people with
dementia. The two types of robots that have been used are therapeutic robots that mimic animals, such
as Paro (a robotic Canadian harp seal developed in Japan; see parorobots.com), and those specifically designed for
health care, also known as healthbots. Evidence in residential health care demonstrates that these robots can reduce
loneliness in those with dementia and increase social interactions.
i) Interoperability
Interoperability is the integration of different applications to making them work seamlessly together.
Application Programming Interfaces (APIs) allow individuals to directly interact with data (including data from biometric
devices such as the UP or Fitbit) in their own applications, products and services. APIs such as the Apple iOS ‘HealthKit
APIs’ enable health and fitness apps to communicate with each other. For example, with a user’s permission, a user’s
blood pressure app could share data with a physician’s app, laying the groundwork for a more comprehensive way to
manage health and fitness via mobile.
APIs will allow apps to talk and create shared networks. Interoperability is the ultimate aim, whereby instead of having
individual software units with limited function, the individual apps will be integrated to create seamless functionality and
cross-functionality. This interoperability will provide visibility into what is going to eventually transform long-term health
management issues.
The opportunities that interoperability opens up for the e-mental health sector are numerous and wide-ranging. For
instance, a mindfulness app would be able to ‘talk’ to the biometric device, which could all be linked into digital
intervention software. Individuals could not only monitor their mental health and wellbeing through dashboards, but they
could also share this information with clinicians to augment face-to-face care. This pilot project has been funded by the
Department of Health and is called Project Synergy.
j) Virtual reality
Virtual reality is the computer-generated simulation of a three-dimensional environment. It is now
beginning to be adopted in certain mental health care situations, especially for those with anxiety
disorders. The advantage of virtual reality is that it can be used to create scenarios that may be impossible to replicate in
real life, for example in the treatment of post-traumatic stress disorder in soldiers.

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24
1.2 INNOVATIVE FUNDING MODELS
We stand at a convergent moment. Previous fragmentation of public funding has led to competitive behaviours between
segment leaders. As a result of interviews, it is clear that the major sector participants believe that the system must be
changed, inclusive of the funding models and are ready to cooperate, show leadership and drive reform of a fragmented
system. Below are some financial models that will facilitate this leadership and cooperation. A common theme amongst
these models is identifying and aligning the interests of various stakeholders, some of which are commercial. Whilst by
no means comprehensive, our discussion groups these models into three categories:
• Structural Funding
• Transactional Funding
• Results Based Funding
1.2.1 STRUCTURAL FUNDING
This category of funding suggestions relates to the development of repeatable, long-term approaches that build and
manage the fabric of research and the integrated system of care.
Public Private Partnerships: There is a significant body of experience around these models. In this
conceptualisation, these arrangements build core research, service delivery or support capability, which
eventually delivers outcomes without the amortised costs of design and delivery, effectively reducing the
marginal cost of activity. This could be used to deliver system wide standardised clinical support systems for the
purpose of supporting big data, universal data interoperability and deep pathway to care analytics.
Leveraged Funds: Programmatic funds that leverage the aggregation of non-government funding pools so as
drive the depth and pace of research and development. A possible variant on this is to ensure that part of the
programmatic funds are reserved for the very tail of the research or delivery program and are awarded based
on outcome achievement. With ‘skin in the game’ seed funders are encouraged towards the promised outcomes
to which pubic funds were applied. This could be used to enable the rapid coalescing of stakeholders around
the development of innovative e-mental health interventions.
Social Impact Bonds: Deployed to address major gaps (such as system design, technology platforms, and
research reform) these instruments bind private risk capital to measurable, often cost reducing, outcomes. The
public purse distributes a percentage of the realised benefit as a reward to the placement of risk capital by the
private sector. This could be used for both infrastructure and components of an integrated system of care.
1.2.2 TRANSACTIONAL FUNDING
This category of funding options relate to the usage costs and charges for resources and services. It is important to note
that these models are not only restricted to service delivery. They can act as incentives for research and development of
new interventions if structured with a sustainability perspective from the start.
Freemium Models: This model is often used in the digital space where a base service is provided free of
charge and a related, expanded, set of services are available for a fee. As long as universal access is not
compromised, this model would be a highly effective incentive to attract private sector into the development of
new e-mental health interventions. It could also be used to encourage them to do so using established evidence
and assessment (as opposed to the unregulated production of apps now)!.
Incentives and Subsidies (MBS and PBS): There is little or no reason to consider e-mental health
interventions that aid clinical sessions, or act in between such sessions, as unworthy of being prescribed by a
professional. Further, if such e-mental health interventions effectively enable self-management and correctly
prevent mental ill health, there is a clear argument to subsidise or incentive their use!.
Micro Payments: Again, this model is common in the digital and crowdsourcing space. The idea is that a large
number of very small payments (for example, $1) accumulate to a significant sum. The advent and emergence
of standing payment gateways (for example, PayPal, Amazon Payments, Apple Pay) on mobile devices mean
that it is a simple click away for an in-app purchase or micro contribution when applicable. !

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Data Monetisation: There is significant interest in big data. While it is public policy to provide data free of
charge to the community, accessing and distributing such data in a digestible format is requiring significant
expense and restructure of public technical infrastructure. There are two opportunities for monetisation of the
de-identified big data in this sector: creating rapid and direct access pathways to raw de-identified data that
update as technologies update; and, leveraging off knowledge within departments and service providers to add
value to the de-identified data. There is precedence for this thinking in the domain of weather (for example, UK
Met Office) where public data, freely available, is now a demanded for-pay product due to the modes of access
to third party commercial providers, as well as the value added to it.
1.2.3 RESULTS-BASED FUNDING
This category of funding could actually be applied across all funding, as is more of a principle than a funding instrument.
The general principle is that all funding be tied to an evaluation framework that directly links public (or philanthropic for
that case) funding to outcomes of the activity. The advent of Social Return on Investment (SROI)-style thinking means
that activities removed from direct service delivery can still be assessed for impact.
There are advocates for and against specific impact assessment methodologies, and it is not the purpose of this paper to
argue one method over another. The critical point is that SROI-style thinking and impact assessment should be tied to
the provision of funding into this sector so as to encourage behaviours towards the elimination of duplicating effort and a
focus on filling system gaps, the enhancement of collaboration by focusing on outcomes not activities, and the
embedding of sector leadership principles by creating a clear line of sight between funding and outcomes to which all
stakeholder are aligned.
SUMMARY
It is the view of this paper that a sophisticated approach to funding is required and that sustainability will demand that
investments will, more than likely, have elements of all three categories combined into hybrids that focus laser-like on
specific outcomes and stakeholder motives.
1.3 POSITION
1.3.1 CURRENT AND EMERGING INNOVATIVE TECHNOLOGIES
An accelerating number of applications, website resources and other technology-based services are emerging
independently and in many cases with a duplicating effect. Very few of these technologies are being designed and
deployed using appropriate assessment and evidence. In summary, there is an expanding supply of uncoordinated and
unsubstantiated technologies. There is little or no structured or systematic use of these technologies in the clinical
service provision settings.
As they stand currently, these services do not achieve the level of benefits that might be obtained in a united and
coordinated system of mental health care. The level of investment in research and evaluation has been minimal and as a
result very few effectiveness evaluations have been undertaken. Although these services promise to reduce demand on
the health workforce, the evidence for this has not been established.
1.3.2 POTENTIAL INNOVATIVE TECHNOLOGIES
There are a number of potential technologies including biometrics, gaming and artificial intelligence. In addition to these,
technologies from fitness and health sectors could easily be ported across to the e-mental health domain. Additionally,
there is an emergence of goal-based reporting or dashboard systems that are drawing data from multiple sources in an
attempt to provide some sort of integrated view on a person’s behaviours. As with the current and emerging
technologies, these potential technologies are fragmented, not coordinated and currently not based on appropriate
evidence and assessment for their use in mental health. One final note is that many of the world’s largest technology
companies (such as Google and Apple) are moving into the mobile wearable space, and it is not hard to see their
platforms or market strengths be applied towards extensions of health such as wellbeing. Also, social media players
such as Google, Facebook and Twitter are each grappling in different ways with the concepts of cyber safety and cyber
resilience under their policy and corporate social responsibility obligations. The areas of cybersafety and cyber resilience
fit squarely into the domains of social inclusion and wellbeing, and as such are part of the mental health domain.

!
26
1.3.3 FUNDING AND TECHNOLOGY TO ENSURE E-MENTAL HEALTH IS PART OF THE SERVICE FRAMEWORK
IN AUSTRALIA
There is need for technology protocols and standards to help coordinate the production and distribution of technologies
into this space. Certification of the technologies being deployed is needed to ensure their efficacious use and give
consumers confidence in their benefits. The development of these technologies needs to be purposefully shifted from
being clinical replacements to being patient-centric designs.
From a clinical perspective, the technologies should interoperate so that it is easy for clinicians to select bundles of
technology that will complement the clinical interaction and be effective in between clinical interactions and further inform
the clinical interaction.
Both of these things call for overarching technology standards that build confidence in and use of e-mental health
interventions.
As an additional layer, a rethink of funding models is required so as to provide financial and credibility support to e-
mental health interventions. This could range from subsidisation of the research and rapid prototyping of new e-mental
health interventions, subsidisation of the licence fees for users of individual interventions (apps), incentives for clinicians
to subscribe and use these technologies, new and innovative models such as impact investing to attract private sector
funds and reduce the burden on the public purse.
1.4 MINOR RECOMMENDATIONS
1. Develop a coordinated ecosystem so as to enable a whole-of-life view and remove duplication.
2. Funding for programs should include a mandatory requirement that 20% of the budget is allocated to R&D,
which includes exploration of sustainable funding.
3. Revise the accreditation program for e-mental health interventions and develop common standards across the
ecosystem so as to build consumer trust in the interventions and ensure data interoperability.
4. Embed access to the online ecosystem in other settings, making the entry point ubiquitous through end user
environments (social media, universities, schools, workplaces, and so on) rather than relying on entry through a
portal.
5. Develop an electronic version of a Pharmaceutical Benefits Scheme (PBS) subsidy and an equivalent Practice
Incentive Payment (PIP) for clinicians to prescribe e-mental health interventions.
6. Develop capability within the sector to analyse and innovate a participant’s own business and funding models
and provide financial support and incentives for their exploration of sophisticated and sustainable business
models.
7. Commission a specific analytical report to quantify the costs and benefits of these changes.
1.5 SUPPORTING MATERIAL
1.5.1 CURRENT RESEARCH FINDINGS
Technology use by Australians is prolific. By 2013, 86 percent of Australians accessed the internet and 44 percent of
Australians used the internet more than five times a day (Sensis and AIMIA, 2013). In 2012, 92 percent of homes had
access to an internet connection almost universally across all demographics (Nielsen, 2012), and with the rollout of the
NBN this is set to increase these percentages further.
Fifty percent of adult mental disorders have their onset before age 15, and 75 percent by age 25 (Kendler and Kessler,
2002). A deeper dive into the findings of technology use of this cohort uncovered the following:

!
27
• Young people are the faster adopters of new and emerging technologies, with 99 percent of young people
using the internet, and 95 percent using the internet daily (Burns et al., 2013).
• Young people are using technologies to access information and assistance in relation to mental health
concerns, which provide a potential alternative to traditional forms of clinical engagement, enabling
professionals to interact via the internet (Burns et al., 2010b).
• Technologically-driven interventions can help encourage the accessing of face-to-face services, "allowing
young people who need intensive services to readily access them whilst also supporting the large number of
young people with mild or moderate mental health concerns" (Kauer et al., 2013).
1.5.2 EXAMPLES OF CURRENT, EMERGING AND POTENTIAL USE OF INNOVATIVE TECHNOLOGIES
Examples of current e-mental health offerings
Recharge is a mobile application developed by the Young and Well CRC in partnership with ReachOut.com and Brain
and Mind Research Institute, which embraces the science of sleep and activity and their interaction with mood. Currently
under trial, it will interface with both wellbeing plans and be used in clinical practice to enhance adherence to treatment
protocols (known as share plans).
Figure 5: Recharge app
Headspace.com (international and not to be confused
with headspace.org) has positioned itself as a personal
trainer for the mind but it also embraces community with
every single user able to track their progress against
‘buddies’. To develop this ‘community’ the organisation
has adopted a ‘freemium’ model whereby users can sign
up for a free ten day challenge with content, videos and
resources assisting the user. If the user then wants to
pursue mindfulness and meditative practices further, they
can pay for a yearly subscription of around $100 (£60) to
get access to the full suite of resources.
Entrepreneur, mindfulness expert and trained monk Andy Puddicombe launched headspace in 2010. From talking at
events, to books and other written materials, to the mobile app service, Headspace is now used in over 150 countries;
with its content translated into 12 different languages. Their aim is that through technology they can enable people to
experience less stress, more contentment and greater clarity in their life.
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!
28
Big White Wall Tavistock and Portman Foundation Trust (UK & NZ)
bigwhitewall.com
Big White Wall provides a peer-to-peer support services coupled with
individual and group ‘talk therapy’. A distinctive feature is the Wall Guides
who are employed by Big White Wall to monitor and support people in
crisis.
It also unique in being a monetised initiative with subsidised and paid
options for joining.
Figure 6: Examples of emerging e-mental health initiatives from the Young and Well CRC
The private sector is also entering this space with products that link data
from different apps and present individuals with personal dashboards (such
as the example opposite from carepass.com).
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© 2012 Zuni | All Rights Reserved | Confidential!

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29
Leading international examples in this space are TicTrac (tictrac.com) and Open mHealth (openmhealth.org).
Tictrac is a Quantified Self (QS) platform that takes lifestyle data and allows users to fully take control of all the variables
in their lives. Tictrac synchronises with data from hundreds of connected apps, devices, sensors, and websites to create
dashboards that empower users with comprehensive lifestyle insights and data visualisation. These insights can enable
users to better understand their unique needs and be able to quantify where they can improve.
Being able to leverage the power of QS data can also be
incredibly valuable for external organisations that can use it
to intelligently drive increased engagement, conversions and
ROI. Tictrac's brand platform enables companies to talk to
their consumers at the right time, with the right message,
through the right channels, based on what their data says is
relevant to them. Their technology has the potential to enable
health insurers, hospital groups, pharmaceutical companies,
mental health organisations and large employers to deliver
individualised care, through intuitive, consumer-friendly
design informed by personalised data.
This will be incredibly valuable in the e-mental health space
because the various apps, websites and software designed
for intervention, education and counselling are currently
disparate and not interoperable. Having a platform that can
capture, synchronise and present the information stored in these individual platforms will be incredibly beneficial. First it
will allow for more effective interventions with those who suffer from depression and mental ill-health but secondly, and
possibly even more valuably, it will create a vast network of data for researchers. This research will hopefully inform
better, more targeted treatment in the future.
Open mHealth is an innovative and potentially
transformative not-for-profit organisation that is attempting
to bring clinical meaning to digital health data. They started
with the mission of building an ‘open mobile health
architecture’ to facilitate integration. With the increasing
popularity of the quantified self (QS) movement, there has
been an explosion of mobile apps and devices designed to
help individuals better track and improve their health. With
that comes huge potential to use the data these health-
focused apps collect to help doctors and counsellors
provide more personalised, preventive care for patients.
Open mHealth have a vision of driving a more effective
‘learning health system’, whereby care and research to
occur side-by-side to generate much greater insight around
what is most effective for treating different patients. Their organisation brings clinicians, data scientists, developers and
designers together to build tools and products that transform the way personal, digital data can be used in health care.
Their argument is that the problem with current data in the e-mental health space is that it is read and written in
inconsistent formats, which make it very hard to integrate, let alone be used in any meaningful way. These challenges
are even greater in the clinical space, where understanding the true meaning of the data can be life critical.
Examples of potential e-mental health initiatives
A key to driving health outcomes is to engage individuals in the management of their own health and wellbeing. It is
instructive to compare and contrast individual online behaviour between the health app ecosystems (including biometrics
devices) and the Personally Controlled Electronic Health Record (PCEHR).
Individual interest in this self-awareness and management is growing as demonstrated by the production and uptake of
mobile health and e-mental health apps as well as biometric devices and the associated ecosystems of apps to which
their data links. As discussed in this paper, these ecosystems are building links between different developers and their
unique apps (via open API) so as to provide each person with a unique dashboard of progress and outcomes against
individual plans (Tictrac, Open mHealth, and so on).
In contrast the financial and transactional systems, such as the PCEHR, have experienced less than optimal uptake and
are not growing in usage or distribution. This transactional information is useful for system funders and policy makers but
as evidenced in Chapter 7, it has little or no utility for individuals in its current form.
© 2012 Zuni | All Rights Reserved | Confidential!

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30
The message this paper wants to draw out of this behaviour is both one of interoperability but even more importantly the
concept of putting the individual at the centre and enabling them to self-design the combinations of resources that meet
their needs. The contrasting online behaviours demonstrate that individuals demand a customisable, single,
consolidated view on their activity, all combined to help them progress, achieve a goal or flourish. To do this, the apps or
interventions need to be able to exchange data (interoperability). By organising these interoperable apps and
interventions into a semi-structured array (some for information, some of management of stress, relationships and some
for later stage care plan sharing), choice plus evidence-based intervention meet in a 'say it once' experience where
people's journey and data are collected along the way and shared as and when it is needed. This is the principle the
Department of Health has invested in by funding Project Synergy.
Figure 7: Synergy: an Integrated ecosystem of e-mental health care
1.5.3 THE CHALLENGE OF STANDARDS AND EVALUATION
A 2013 report by mobile health consultant group Research2Guidance (Global Observatory for eHealth series, 2011)
found more than 97,000 mobile health applications, listed on 62 full catalogue app stores. The majority of these
applications are general health and fitness apps that both facilitate the tracking of health parameters by private users,
and provide users with basic health and fitness related information, as well as guidance.
A Reuters article releasing further details of the report states that “some 15 percent (of the 97,000+ apps) are primarily
designed for the healthcare profession”, implying that the remaining 85 percent are designed for users to promote their
own health and wellbeing.
Most existing and emerging standards for apps in this field exist outside of Australia. A 2011 report by the WHO Global
Observatory for e-Health (Global Observatory for eHealth series, 2011) indicated the following regarding policy-making
around mobile health technologies: “mHealth is no different from other areas of e-Health in its need to adopt globally
accepted standards and interoperable technologies, ideally using open architecture. The use of standardised information
and communication technologies would enhance efficiency and reduce cost. To accomplish this, countries will need to
collaborate in developing global best practices so that data can move more effectively between systems and
applications.”
The international survey on which the WHO mHealth report (World Health Organization, 2011) is based provides details
of policies from all responding countries. The overall picture is an uneven one, with significant progress in some
countries such as Finland, with its Office for Health Technology Assessment (Finohta), which is now a medium-sized
health technology assessment (HTA) agency, to very limited advances in most others.
In July 2011, the US Federal Drug Administration (FDA) published draft guidance in which it proposed regulating any
mobile app deemed to be a medical device. It stated it would not regulate personal wellness apps such as pedometers or
heart-rate monitors.
According to the mHealth Alliance ‘lawmakers in the US and the European Union (EU) are currently working to define
regulatory frameworks that achieve a balance between patient safety and innovation. The US House Energy and
Commerce Committee held a series of hearings on mHealth apps on 19-21 March 2013, to examine to what extent the
!
!
Overview'
Project!Synergy!is!an!e0mental!health!
ecosystem!of!certified!partner0
developed!technologies!that!interact!so!
as!to!make!it!faster!and!easier!for!young!
people,!and!their!carers,!to!access!
services!and!information!appropriate!to!
their!immediate!needs.!!
The!technology!solutions!do!not!impede!
or!take!away!from!existing!services!but!
rather!build!on!their!current!offering.!
Potential!solutions!include:!common!
standards!and!protocols;!a!sign0on!
system!that!allows!young!people!to!
own!their!own!data;!with!agreement!
longitudinal!tracking!and!data!storage.!!
In!essence,!Project!Synergy!will:!
• Provide!a!technology!solution!for!
online!mental!health!and!wellbeing!
services!with!interoperability!that!
allows!data!to!be!captured!and!
stored!across!multiple!services.!
• Provide!services!can!be!tailored!
according!to!individual!needs.!!
• Utilise!the!Institute!of!Medicine’s!
Quality!Framework!for!Health!
Care,!where!the!internet!is!a!
setting!for!the!the!provision!of!
mental!health!services!
!
Rationale'
Say'it'once:!Data!transfer!between!
components!of!the!ecosystem!enabling!
ease!of!access!and!ownership!of!
information.!Further,!young!people!will!
be!placed!at!the!centre!of!this!
ecosystem!managing!access!to!their!
own!data.!
Common'standards:'ensure!
interoperability!and!enable!the!sharing!
of!information.!!
Common'analytics:!shared!analytics!to!
understand!user!pathways.!
Data'centricity:!will!provide!new!
volumes!and!types!of!data!for!research!
and!translation!all!managed!within!a!
secure!data!storage!facility!to!ensure!
privacy!and!compliance!with!medical,!
legal!and!ethical!standards.!!
Prototyping:!in!line!with!the!Young!and!
Well!CRC’s!approach,!Project!Synergy!
will!provide!a!pathway!for!rapid!
prototyping!of!new!e0mental!health!
interventions.!
Figure!5:!Project!Synergy!
Ecosystem!

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31
FDA should oversee and regulate medical applications on smartphones and tablets, and the FDA committed to releasing
final guidance on mHealth apps by the end of fiscal year 2013. The EU, meanwhile, has focused on creating a
framework for medical devices’ (Kritsky, 2013).
It is important to note the role of the private sector in the field of assessment of apps. A notable example is Happtique,
which describes itself as a digital and mobile platform for the curation, certification and prescribing of mHealth apps.
Happtique's has a curated application store with more than 15,000 mHealth apps categorised into more than 330
categories, including physician specialties/professions and medical, health and fitness topics. Happtique runs a
certification program for medical, health and wellness apps. In 2014 it will launch the Happtique App Certification
Program (HACP), ‘a voluntary program designed to help consumers, physicians and other healthcare providers identify
mHealth applications that meet high operability, privacy and security performance criteria and are based on reliable
content’ (Happtique, 2012). HACP will address standards in four areas: operability, privacy, security and content.
Filling the gap of consumer confidence
The Young and Well CRC in partnership with The Queensland University of Technology developed the Mobile
Application Rating Scale (MARS) and the methodology to support the evaluation of apps in 2012. This was due to the
lack of a recognised comprehensive, reliable and objective instrument to rate the degree that mobile health applications
satisfy the quality criteria of both evidence based content and usability, which are both needed to effectively provide a
suitable intervention for mental health and wellbeing issues (Hides et al., To be published 2014). !
The development of the MARS utilised a wide range of existing website and app assessment criteria identified in
previous research, from which irrelevant criteria and duplicates were removed. An advisory team of psychologists,
interaction and interface designers and developers, as well as other professionals involved in developing mental health
and wellbeing applications, worked together to classify assessment criteria into categories, sub-categories and finally
develop scale items and descriptors.
In its development the scale was tested across 60 randomly selected mobile apps, which found that it provided an
excellent level of inter-rater operability, as well as excellent consistency in its scoring. The scale has been recognised by
healthcare and professionals as an easy-to-use, simple, objective, reliable and widely applicable measure of app quality,
developed by an expert multidisciplinary team (Hides et al., To be published 2014).
MARS Structure
The scale has been developed so as to provide an objective and reliable multi-dimensional measure of the quality
of health-related apps. There are three main structural parts to the scale:
1. App Classification (not scored)
The classification is used to record the descriptive and technical information on the app, including focus;
theoretical background; affiliations; target group; and technical aspects of the app.
2. App Quality Rating (Scored)
Quality is rated on four dimensions, each of which are rated on a 5 point scale (where a score of 1
indicating poor quality and 5 indicating excellent quality)
•Engagement – the app is interesting and /or fun to use
•Functionality – the app works appropriately
•Aesthetics – the app has good visual design
•Information – the app contains quality information from reliable sources
3. App Satisfaction Ratings (Scored)
This is focused on rating from the perspective of a user as to the perceived value of the app.
The MARS utilises total scores as the indicator of quality and satisfaction for the tested mobile app.

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32
In terms of rating portals, the work of Professors
Helen Christensen and Kathy Griffiths created
the Beacon web portal (Beacon.anu.edu.au),
which provides a free guide to the content and
effectiveness of online behavioural interventions,
mobile apps and internet support groups
worldwide. Developed and maintained by the
Australian National University, the scientific
evidence underpinning every intervention is
systematically reviewed according to best
practice principles and a smiley-face rating
system is used to provide users with a guide to
what works. Beacon also summarises the
content, type and length of each intervention, its
intended audience, whether it is free or fee-
based, the languages in which it is available and
the findings of the research trials that have
investigated whether it works. Users are also
given the opportunity to provide their own ‘consumer’ ratings and comments about each website much as TripAdvisor
enables users to share their experiences of products. For each condition, visitors can filter by target age group, whether
registration is required and level of evidence (for example, they may choose to select CBT interventions for adolescents
with very strong evidence of effectiveness). Apps can be filtered by type of platform (Apple versus Android). Although it
was previously funded by the Department of Health, Beacon is currently unfunded, however, this is the type of ‘portal’
that the government should be investing in because it uses an evidence-based framework to evaluate online
interventions. That said, it currently sits within the ANU ecosystem and is not mainstreamed. Ideally, it should sit within
an integrated e-Mental health system, with a focus on UX feature and functionality improvement, to make it more
attractive to end users to increase uptake. Finally, it should be interoperable across different gateway sites, such as
Lifeline, beyondblue, headspace and ReachOut.com. Additionally, counsellors and primary health care providers could
be using it to recommend evidence based online CBT, IPT, mindfulness etc.
In terms of work to date towards developing standards for e-mental health, the following standard measures pack was
developed by the Young and Well CRC in partnership with Internationally recognised thought leaders in technology and
innovation including researchers from the Pew Internet and American Life Project, the Berkman Center at Harvard
University, the Microsoft Research Centre and the EU Kids Online project. The standard measures pack is constantly
evolving but aims to create internationally recognised minimum data set to be used across e-mental health projects to
ensure comparability:
!
Measure'
Instrument'
Reference'
Demographics-
Young-and-Well-National-Survey-
Based-on-ABS,-headspace-and-beyondblue-community-surveys.-Gender-
and-sexuality-questions-developed-with-National-GBLTI-Health-Alliance.-
Mental-Health-
Kessler-10-
Kessler-RC,-Barker-PR,-Colpe-LJ,-Epstein-JF,-Gfroerer-JC,-Hiripi-E,-et-al.-
Screening-for-serious-mental-illness-in-the-general-population.-Arch-Gen-
Psychiatry.-2003-Feb;-60(2):-184[9.-
Wellbeing-
The-brief-14[item-version-of-the-
Mental-Health-Continuum-–-Short-
Form-(MHC[SF)-
The-Oxford-Happiness-
Questionnaire:-a-compact-scale-for-
the-measurement-or-psychological-
well[being.-
Lamers,-S.,-G.-J.-Westerhof,-et-al.-(2011).-“Evaluating-the-psychometric-
properties-of-the-mental-health-Continuum[Short-Form-(MHC[SF).”-
Journal-of-clinical-psychology-67(1):-99[110-
Hills,-P.,-&-Argyle,-M.-(2002)-The-Oxford-Happiness-Questionnaire:-a-
compact-scale-for-the-measurement-or-psychological-well[being.-
Personality-and-Individual-Differences,-33:-1073-[-1082.-
Technology-Use-
-
Developed-by-Young-and-Well-CRC-working-group;-Adapted-from-Young-
and-Well-CRC-National-Survey-and-EU-Kids-Online-survey-
!

!
33
1.5.4 THE SHIFT TO INNOVATIVE FUNDING MODELS
The government context!
Investment in e-mental health has decreased in recent years, from $70.4 million from 2006-2012, to $15.4 million for
2012-2015. This represents a 56% drop, which is at odds with the evidence around the uptake of technology and
economies of scale in terms of service provision.
While specific organisations have received continuing financial support for the development of mental health
infrastructure for example, headspace (10 new face-to-face bricks and mortar centres) and Orygen Centre of Excellence
for Youth Mental Health ($18 million), the Young and Well CRC ($5 million for Project Synergy) is the only organisation to
receive funding solely dedicated to e-mental health. The overarching result of this changed environment is that the
funding envelope is shrinking, despite clear evidence of increasing demand and burden of disease. This is an
unfortunate but reversible situation.
This articulates a policy view that goes beyond ‘doing more with less’ or shifting the burden to ‘individual giving’. This is a
hard shove towards innovation in sector funding, and the message is that the drivers for this innovation cannot come
from government alone.
There are two levels of dialogue about funding innovation. What is common to both is the need to shift the system (be it
e-mental health, Mental Health Services, or Health Services) from treatment to prevention and to do this the approach
must move from being system-centric to being individual-centric.
The first level for fundamental reform is not new. There is merit in the arguments for micro economic policy to
fundamentally facilitate the shift to being person-centric. Focusing on prevention will encourage people, practitioners,
insurers and other stakeholders to move into the territory of prevention over care. An interesting position on this reform is
provided in the Business Council of Australia’s (2011) paper titled “Using microeconomic reform to deliver patient-centred
health care”.
The Productivity Commission articulated a number of microeconomic reforms that, like the reforms of the 1990s, led to a
fundamental shift in productivity in other sectors. The mental health care sector is also in need of such reform. At their
core is the need to move away from a system that rewards activity for managing illness and helping sick people get
better, towards a system that keeps people mentally healthy and well.
The second level is an allocation dialogue, which is about creating effective and cost effective methods for individuals to
take control of their own wellbeing and in doing so shift not only the quantum of demand but also move the less complex
issues out of the clinic onto platforms well suited to them, freeing premium clinical space for those with complex issues.
The key to this second dialogue is to mobilise sophisticated commercial models to speed the development of innovative
interventions and distribute them. Given the scope of this paper, the focus will be on the second level dialogue.

!
34
Some of the innovative actions taking place with regards to funding include:
Categories
Sub Categories
Examples that can be leveraged
Structural Funding
PPP
" The 2003 ‘Second National Mental Health Plan’ was
developed with an understanding that the relationship
between public mental health services and the private
mental health sector is one of the key partnerships in
service reform and delivery
Leveraged Funds
" Young and Well CRC: Young People, Technology and
Wellbeing
" Hearing CRC: Cochlear Implants
" Vision CRC: Soft Contact Lenses
Social Impact Bonds
" Uniting Care in NSW keeping children out of foster care
achieved a 7.5% yield ROI due to cost savings
Transactional Funding
Freemium
" The headspace meditation app offers a free introductory
ten-week: ‘Take10’. If the user has enjoyed the content
then they have the option to take advantage of the full
program where they have access to a wide range of
resources.
Incentives
" The Medicare Benefits Scheme (MBS) and Pharmaceutical
Benefits Scheme (PBS) reward Medical Practioners and
subside patients on a per service basis, encouraging
uptake of these services.
Micropayments
" In the same way that many mental health apps have begun
to ‘game-ify’ the way their content is presented – users
earn badges and climb levels – the example model of
popular app ‘Candy Crush Saga’ could be leveraged. In this
mobile application, users are given 3 chances to fail, once
they do the game will not allow them to progress unless
they wait 48hrs or give a micropayment of $0.99 to
continue immediately.
Data Monetisation
" Weatherzone is a premium service for the provision of
weather information. It aggregates data supplied by the
Australian Bureau of Meteorology and converts this data
into a premium product by making it computer ready,
providing bespoke forecasts and TV or web ready graphics.
Results Based Funding
SROI
" An SROI analysis undertaken by the social enterprise
STREAT allowed the organisation to capture data that
measured which of their initiatives were providing value and
those that weren’t as effective. Additionally, this analysis
allowed the organisation to provide consistent measures of
the expected impact and value of their activities for
stakeholders such as investors.
A challenge to many of these models is shifting practitioner perspectives around e-mental health interventions. Anecdotal
evidence suggest their primary concern about prescribing such interventions are around questions of:
• Evidence base
• Misdiagnosis or misdirection
• Privacy of data collected or maintained within the technologies!
Interestingly, Digitas Health surveyed 2,000 patients with 20 different cardiac, gastrointestinal, and respiratory diseases
as well as CNS and diabetes conditions and found that a staggering 90 percent of chronic patients in the US would
accept a mobile app prescription from their physician, as opposed to only 66 percent willing to accept a prescription of
medication, according to a recent survey from health communications firm Digitas Health (Cohen, 2013).

!
35
2. The current e-mental health landscape
2.1 SNAPSHOT OF THE CURRENT E-MENTAL HEALTH OFFERINGS
IN AUSTRALIA
The diagram below maps key examples of e-mental health offerings in Australia:
Figure 8: Illustrative examples of the current e-mental health landscape in Australia
There is no doubt that there is duplication and wastage within the mental health system and a less than optimal approach
to providing the right help at the right time. The diagram above is a graphical depiction of the brands, resources and
online supports available to the Australian consumer. The private sector is also entering the e-Mental health space, e.g.
Medibank, Telstra Health and Bupa. Using categories on the x-axis above, these private sector participants are active in:
Information Websites, Portals, Web Enabled Chat and Crisis and Telephone Support. In terms of the y-axis, they are
focused on Clinical Need rather than Wellness, so would skate across the top of the diagram. This picture does not
include international offerings (BigWhiteWall and headspace.com). Also missing from the diagram are state and local
level offerings!. To add further to the complicated landscape is ‘scope creep’ where organisations have sought and
gained funding, which may not be a part of their national remit. Organisations have diversified but it has been ad hoc,
without strategy and without a unified approach to creating an integrated system of mental health care, which includes e-
mental health as a core component.

!
36
The service sector is unanimous in its commitment to work in a united, coordinated and collaborative way. That said,
they also raised areas of concern that worked against the sector uniting under one common agenda or vision for the
future:
• Funding cycles are short (2-4 years) and uncertainty without backbone support breeds duplication, waste and
competition;
• Federal and State systems are not aligned which creates fracture and segmentation, specifically in relation to
providing wraparound care for people and their families (based on interview feedback);
• The current funding model is heavily weighted towards illness and medical models of care; distribution of funding
should be tailored to suit a public health approach (based on interview feedback).
This next diagram aligns to the previous map, however aims to contrast the areas of e-mental health in Australia that
have some duplication against those that have gaps (as per data collected, see Appendix 1):
Figure 9: Areas of gaps and duplication in e-mental health in Australia
At a simple level, areas of duplication includes:
• The provision of ‘information only’, this duplication can be seen across federal and state information websites,
within and between departments and specifically in relation to simple things like fact sheets, as demonstrated
from the data collected through this engagement (Appendix 1). A data bank, or content management system
that collated all material and made it available across syndicates would address this issue (in the same way
media is syndicated and shared);
• Gateway services have a clear role to play in building community, reducing stigma and enhancing clear
pathways to care between services. That said duplication of effort exists across major Gateway Services
including beyondblue with 2.5 million unique users each year, ReachOut.com with 1.5 million unique users each
year and eheadspace with 1.2 million unique users each year. Coordination of effort and clear delineation of
roles would significantly enhance pathways to care across the three major sites;

!
37
• Crisis support services such as Lifeline and Kids Helpline, similarly provide call services that reach 820,000 and
250,000 callers every year. Duplication occurs with other providers such as beyondblue and eheadspace but
simple coordination of effort and agreed protocols for referrals, warm transfer and call back would address
pathway challenges while protocol training for front-line staff regarding e-mental health resources and
consistent and shared help seeker information would address this;
• Online therapy, both self-directed and therapist-guided, is lacking coordination. As the Beacon portal
showcases, psychoeduction, online therapy and support groups cover 40 core topic areas, however this has not
been comprehensively mapped into an ecosystem of care, with consideration given to data sharing, technology
standards and common protocols;
• A significant gap, and one that the sector is keen to support is the role of peer-to-peer and family support
forums (see Appendix 1). This area is being led by SANE and reachout.com and with leadership across the
sector could easily be embedded into current service offerings such as web-enabled chat, online counselling
and information sites.
• The role of Mindhealthconnect is not clear. This was reflected by comments from service providers. From an
evidence informed perspective when considering reach in 2014 Mindhealthconnect funnelled 100,088 visits to
information partners; approximately 14 percent went to beyondblue, 12 percent to Mentalhealthonline, 11
percent to reachout.com. For beyondblue given they have 2.5 million unique users this is less that .006 percent
of their user base and creates an additional layer of complexity for the consumer. The recommendation is to
cease funding this initiative and reallocate funds elsewhere as this is providing a duplicative, ineffective service.
Common and shared views on the way forward arising from sector interviews, include the following:
• The building blocks are in place and the sector has a united and shared vision which includes common
standards and protocols, data capture and data sharing;
• More work needs to be done to ensure integration with face-to-face offerings;
• More work needs to be done to create relevant resource for vulnerable populations including men, rural regional
remote, people who are indigenous, NESB or living with a disability;
• Leadership can be garnered in specific areas and tighter commitment given to a reduction in duplication which
can be addressed by building an ecosystem of e-mental health care;
• Significant investment has positioned Australia as a world leader and innovator in e-mental health; this
infrastructure and focus on R&D and rapid prototyping should not be lost;
• Sustainability and certainty of funding is a core element in moving from start-up to sustainability and the sector
has a keen interest in leveraging funds and building models that showcase the role of government, NGO,
University, Industry together;
• Consumer choice is critical, a reduction in duplication can be achieved with greater co-ordination of ‘behind the
scenes’ systems, this maintains and continues to provide choice to consumers and ensures greater allocation of
funds to innovation and R&D; and
• Data capture is critical for consumers, service providers, government and policy makers. If managed with the
consumers needs in mind it will be empowering, seamless in its integration, reduce the need to tell the story
numerous times and provide service makers with a clear way to improve service offerings and work towards
efficiency in provision of service and better outcomes for the consumer.

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38
2.2 DEFINITIONS
e-health – “The cost-effective and secure use of information and communication technologies in support of health and
health-related fields, including health-care services, health surveillance, health literature, and health education,
knowledge and research.” (World Health Organization, 2005)
Electronic health records – “An electronic longitudinal collection of personal health information usually based on the
individual, entered or accepted by healthcare providers, which can be distributed over a number of sites or aggregated at
a particular source. The information is organised primarily to support continuing, efficient and quality healthcare. The
record is under the control of the consumer and is stored and transmitted securely.” (National E-Health Transition
Authority, 2008)
e-learning – “e-learning services comprise education and training in electronic form for health professionals. e-learning
can improve the quality of education, increase access where learning resources are unavailable, or use new forms of
learning.” (WHO, 2012)
e-mental health – “...that form of e-health concerned with mental health... e-mental health services provide treatment
and support to people with mental health disorders through telephone, mobile phone, computer and online applications,
and can range from the provision of information, peer support services, virtual applications and games, through to real
time interaction with trained clinicians.” (Australian Government, 2012)
m-health - Describes services and information provided through mobile technology, such as mobile phones, portable
computers. It may include data collection; real-time monitoring of patients; treatment support, health advice and
medication compliance; health information and education programs to patients, practitioners and researchers; and
diagnostic and treatment support and communication for healthcare workers.
Personally Controlled Electronic Health Records (PCEHR) - The PCEHR is a component of the Australian
Government’s e-health reform agenda, which commenced in July 2012. The system is designed to enable the secure
sharing of health information between an individual’s healthcare providers, with the individual controlling who can access
their e-health record.
Social media / Web 2.0 – “An interactive, participatory and collective approach that encourages self-expression and the
building of online communities” (Burns et al., 2010b). Social media may be used to promote e-mental health programs, or
it be a component of an e-mental health program
Telemedicine / telepsychiatry – “The delivery of health care services (where distance is a critical factor) by all health
care professionals using information and communication technologies for the exchange of valid information for diagnosis,
treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health
care providers, all in the interests of advancing the health of individuals and their communities.” (WHO, 2012)

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39
2.3 A BRIEF HISTORY OF E-MENTAL HEALTH IN AUSTRALIA
The notion of e-mental health has evolved over time, from telehealth and online portals for storing data, to the holistic
concept where technologies are used in an integrated manner for the improvement of mental health and wellbeing.
Often when discussing e-mental health, an assumption is made that e-mental health is simply 'telemedicine', a term
coined in the 1970’s literally meaning "healing at a distance", with its purpose to overcome geographical barriers to
provide clinical support using various types of technologies to improve health. Another common assumption is that e-
mental health is the Commonwealth Government's eHealth Record System, introduced in 2012 as a personally
controlled, secure online summary of health information, allowing patients to share health information with healthcare
providers (see Chapter 7).
While both telemedicine and eHealth Records are important elements of e-mental health, the first major policy document
was written over a decade ago 'e-mental health in Australia: Implications of the Internet and Related Technologies for
Policy (Christensen et al., 2002)' — where the term 'e-mental health' was used to refer to mental health services and
information delivered or enhanced through the internet and related technologies.
Major involvement from Government includes the Telephone Counselling, Self Help and Web-based Support
Programme, established in 2006 and the e-mental health Strategy for Australia, announced in 2012.
The diagram below provides a brief overview of the major developments in online interventions mapped against the
development of social networking services, to provide the context relating to technology innovation.
Figure 10: Overview of major developments of online interventions In Australia and social media
THE CASE FOR E-MENTAL HEALTH
2015!
1995!
Hotmail!
1996!
Google!
1998!
MSN Messenger!
1999!
ReachOut.com!
1997!
Kids Helpline (online)!
2000!
Skype!
2003!
Skype
Facebook!
2004!
Twitter!
2006!
Tumblr!
2007!
Instagram!
2010!
SnapChat!
2011!
beyondblue!
2000!
Youth
beyondblue!
2003!
eCouch!
2005!
Virtual Clinic!
2007!
Mental Health
Online!
2011!
eheadspace!
2011!Suicide Callback
Service!
2013!
1997
SANE!
1997!
Myspace!
2003!
Butterfly
Foundation!
2002!
2005
Beacon 2.0!
2010!
This Way Up!
2012!
Mindhealthconnect!
2012!
2013
Mindhealthconnect
Mindspot Clinic!
2013!
Young and Well
CRC!
2011!
!
#$%&$'!($)'*+'$)&,$-!
.,/&0%!1'2&0!

!
40
The opportunities of e-mental health are typically framed in two areas:
1. The potential for efficiencies and greater value for investment in terms of reach and access
2. The potential to improve outcomes through enhancing access and self-efficacy
For example, a recent briefing paper from the NHS (2013) captures this dual focus:
“Digital technology has revolutionised the way we conduct our everyday lives. The expectations service users
and their families have of mental health services, and how they interact with them, are also changing rapidly…
[it] could help us address resource challenges… and also has the potential to support cultural transformation
and a move towards a social model of health, by empowering service users to exercise greater choice and
control and to manage their own conditions more effectively.”
Similarly a rapid review of the e-mental health literature (Lal, 2014) concluded:
“Many believe that e-mental health has enormous potential to address the gap between the identified need for
services and the limited capacity and resources to provide conventional treatment. Strengths of e-mental health
initiatives noted in the literature include improved accessibility, reduced costs (although start-up and research
and development costs are necessary), flexibility in terms of standardization and personalisation, interactivity,
and consumer engagement”.
Within the Australian context the discourse is consistent, for example (Christensen and Hickie, 2010b):
“If we are to substantially reduce burden we need to develop more accessible, empowering, and sustainable
models of care. E-health technologies have specific efficiencies & advantages in the domains of promotion,
prevention, early intervention, and prolonged treatment. It is timely to use the best features of these
technologies to start to build a more responsive & efficient mental health care system”.
In 2010 and again in 2014, many individuals across the NGO and University sector united to write recommendations for
considering the use of technologies in mental health service delivery. The arguments are simple, but are worth restating:
• E-mental health services enable consumers confidential, flexible access to services through preferred methods
of contact, i.e. contact can be made from home, at all hours of the day, and in ways that do not require
disclosure to friends or family members. Immediacy of access is especially important for delivery of services to
people from rural and remote locations, and this feature will have substantially increased impact as broadband
becomes universally available.
• Access at low cost and in flexible, non-stigmatising ways is particularly important for people with high-
prevalence, low-severity disorders, who are over-represented in the group who currently are not receiving
treatment.
• E-mental health services can also be used as an adjunct to face-to-face treatment or as a guide for treatment
sessions, ensuring high fidelity, evidence-based care, and building the capacity of practitioners.
• E-mental health services can reach consumers in rural, regional and remote locations who are often severely
under-served.
Potential stakeholder benefits related to e-mental health can be summarised as follows:
Individuals:
• Overcome the traditional barriers to access mental health services (for example, the stigma, cost, geographical
location, transport difficulties, social isolation, a lack of services)
• Provide immediate, convenient and flexible services which will be aided by the rollout of the National Broadband
Network
• Deliver confidential care
• Provide easy access to personally controlled care
• Empower people to choose care that meets their needs, and enable them to set the pace of their care and
journey to recovery
• Provide treatment for people experiencing multiple mental health conditions
• Deliver high-quality care that is in line with best practice guidelines.

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41
Health professionals:
• Reduced demands on the mental health workforce
• Ensures that clinicians utilise their skills for more complex care
• Effectiveness and efficiency of face-to-face services may also be improved by e-mental health services
• Potential provision of a pathway to face-to-face care (and therefore reducing the reliance on crisis services)
• Can potentially use e-mental health interventions as an adjunct to face-to-face treatment
• Refer to e-learning tools and the availability of clinical practice guidelines
• Enjoy improved access to professional education and support resources.
Governments, and the broader community:
• Efficiency of this mode of service delivery.
• Reduction in inequities in health, by targeting population groups that currently do not receive treatment, and
may most benefit from services.
• Improved population health planning and service delivery as a result of online data collection and information
management
• Implementation support of a public health intervention on a mass scale.
2.4 CURRENT TYPES OF E-MENTAL HEALTH SERVICES IN
AUSTRALIA
E-mental health programs or services have expanded rapidly in the past decade, and have been developed for virtually
every component of conventional mental health services. The diagram below outlines the broad types of e-mental health
(Christensen 2003; Taylor 2003; Ybarra 2005).
Figure 11: Types of e-mental health offerings in Australia
Information Provision"Gateway Services
and Portals"
Screening and
Assessment"
Social Support"Prevention and Early
Intervention"
Cognitive Behaviour
Therapy Online"
Web Enabled Chat"Telephone Support"Recovery and Mutual
Support"

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42
The following examples provide illustrations of such offerings in Australia.
2.4.1 INFORMATION PROVISION
The provision of mental health information is a foundational type of
E-mental health. Typically these e-mental health initiatives are
websites of ‘static information’ – that is, information that only web
administrators can create, edit, delete and publish to the website.
Mental Health Australia
mhaustralia.org
A national non-governmental organisation founded to represent and
promote the Mental Health sector in Australia. They provide
factsheets, promote research around issues in Mental Health and
publish articles from experts in the field.
Mental Health Association of NSW
mentalhealth.asn.au/programs
They are primarily focused on the provision of mental health
information and running anxiety and health promotion programs
within NSW, including co-ordinating Mental Health Month NSW,
seminars, projects and public forums.
Victorian Transcultural Mental Health
vtmh.org.au
The VTMH is a statewide unit which supports area mental health
and psychiatric disability support services in working with culturally
and linguistically diverse (CALD) consumers and carers throughout
Victoria. They provide education and professional development,
aggregation of services (interpreters, and so on) and seminars.
Australian Department of Health
health.gov.au
This national, government website gives users access to
information for a wide range of issues, across health professions. It
provides aims to promote, develop and fund health care services
for the Australian. Additionally the ADH provides public information
on grants, links to online intervention resources, and health
information and assurance for inbound and outbound travellers.
!

!
43
2.4.2 GATEWAY SERVICES
There are a number of gateway services that relate to health promotion, wellness promotion and psycho-education,
which include:
Beacon
beacon.anu.edu.au
Beacon is a website application that assigns ratings that
assess the scientific merit of existing mental health
programs and provides users with information on which
programs have been shown to be most effective.
Bluepages
bluepages.anu.edu.au
BluePages provides information on treatments for
depression based on the latest scientific evidence. It also
offers screening tests and quizzes for depression and
anxiety, and links to other helpful resources.
Mindhealthconnect
minhealthconnect.org.au
A source of mental health and wellbeing information, online
programs, helplines and news on developments in the
mental health sector. It also serves as an aggregator
providing access to trusted mental health resources from
the leading mental health providers in Australia, allowing
users to make informed choices about their own mental
health.
ReachOut.com
au.reachout.com
ReachOut.com is one of Australia’s leading online youth
mental health services, targeting the under 25 age group
with areas across motivation, depression, health, sexual
health and sexual orientation amongst others. The
organisation provides factsheets, stories, videos, guides,
tools and apps to help educate their audience. Additionally
their is a reachout.com forum to allow users to connect
with other young people, chat to experts and share their
tips for health and wellbeing

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44
2.4.3 SCREENING AND ASSESSMENT
Screening and assessment tools have been available for many years on stand-alone computers. More recent
developments are internet-based screening and assessment tools for broader access by individuals for self-assessment
and for use by professionals in specific settings (for example, primary care).
Mental Health Online
mentalhealthonline.org.au
Mental Health Online (formerly Anxiety Online) is an
internet-based treatment clinic for people with mental
health problems. It is an initiative of the National
eTherapy Centre (NeTC) at Swinburne University of
Technology. The organisation focuses on clinical
assessment, publicly accessible treatment programs
that can be self-help or therapist-assisted and research
trials to improve approaches in the mental health sector.
Turning Point
turningpoint.org.au
Turning Point Alcohol & Drug Centre was established in
1994 to 'provide leadership to the alcohol and drug field
in Victoria'. They provide online self-assessment for
individuals who may be affected, educational materials,
undertake research and provide access to other
resources in similar fields.
The Butterfly Foundation
thebutterflyfoundation.org.au
The Butterfly Foundation is an organisation dedicated to
bringing about change to policy and practice in the
prevention, treatment and support of those affected by
eating disorders and negative body image. They provide
depression self-testing, temperament and personality
tests and wellbeing questionnaires.
2.4.4 SOCIAL SUPPORT
Social support includes discussion groups, forums bulletin boards, chat rooms, blogs, and social media.
These sites are mainly established by service users and provide peer based support, information and advice based on:
• Diagnoses – depression, mood, anxiety, psychosis, eating disorders, and so on.
• Help-seeking options – services, self-help, medication, therapies, and so on.
• Key issues – stigma, employment, housing, social exclusion, human rights, and so on.
SANE Australia
sane.org
SANE Australia has a mission ‘to help all Australians affected by
mental illness lead a better life'. They support this in three ways:
Education, Support and Training. Educational resources include
Guidebooks and ebooks, Factsheets, podcasts, videos, Guidelines
for health professionals and a magazine. All resources are
available online in digital and print format. Additionally they also
provide live cha support, and online forum support.

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45
ReachOut.com and BluePages (both previously featured)
2.4.5 PREVENTION AND EARLY INTERVENTION
E-mental health interventions can have the following variables:
• Stage – promotion, prevention, early intervention, treatment, maintenance, relapse prevention
• Structure – service user led or professional/therapist led | individual or group
• Relationship – professional/therapist with service user or between service users
• Therapy modality – cognitive behavioural, problem solving, psycho-education, and so on
• Role – primary intervention or adjunct to conventional intervention
BITE BACK
biteback.org.au
BITE BACK is a program run by Black Dog Institute, aimed at
promoting mental health through community forums and
blogging that share personal stories, educational videos and
interviews of thought-leaders. The program provides resources
to allow young adults to check and track their 'mental fitness'
via quizzes and its mission is to promote self-esteem, creativity
and individuality.
Climate Schools
climateschools.com.au
Climate Schools Australia provides health and wellbeing
courses that are a mix of online cartoon scenarios and
activities targeting school-based prevention of bullying and
mental ill-health.
Mind Matters
mindmatters.edu.au
MindMatters aim to support secondary schools to promote and
protect student mental health. They utilise a framework of tools
and modules that aims to promote mental health, prevent
problems and enable early intervention.
!

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46
2.4.6 COGNITIVE BEHAVIOUR THERAPY ONLINE
There is a high prevalence of online CBT programs available in Australia, as demonstrated by the following examples:
e-Hub & MoodGym, Australian National University
ehub.anu.edu.au
The e-Hub is a portal of e-mental health options with MoodGym
providing a depression prevention intervention. It consists of five
modules based on cognitive behavioural therapy and includes an
interactive game, assessment and feedback, workbook and
relaxation audio content.
MoodGym is an innovative, interactive web program designed to
enable users to learn cognitive behaviour therapy skills for
preventing and coping with depression. It consists of five
modules, an interactive game, anxiety and depression
assessments, downloadable relaxation audio, a workbook and
feedback assessment.
THIS WAY UP
thiswayup.org.au
Online treatment, education and research in anxiety and
depression. They provide an online clinician assisted
treatment program and provide information and technical
training for clinicians. Additionally there is a self-help
program with guides to common mental disorders,
psychological strategies and outcome measures. An
internet-based learning system that provides health and
wellbeing courses for school students is also available.
MindSpot Clinic
mindspot.org.au
Online assessment and treatment for anxiety and
depression. Services can be accessed online or via
telephone for free and they also provide education and four
to six week courses with access to a MindSpot clinical
resource.
Brave Online
brave.psy.uq.edu.au
Internet-based cognitive behavioural treatment for anxious
young people. Targeted at children (aged 7 to 12) and
teenagers (aged 13 to17).

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2.4.7 WEB ENABLED CHAT
A few services in Australia also offer live, web-enabled chat for people to interact with a professional e.g. instant
messaging, forums etc.
eheadspace
eheadspace.org.au
A confidential, free and secure space where young people can
talk, email or speak on the phone with qualified youth e-mental
health professionals. Family members are also able to utilise
this service for relations who are 12 to 25 and are beginning to
become a concern with regards to their mental health.
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QLife
qlife.org.au
QLife is Australia's first nationally-oriented counselling and
referral service for people of diverse sex, genders and Intersex
(LGBTI) people. QLife is an initiative of the Department of
Health’s Teleweb project. Whilst keeping a focus on telephone-
based counselling they also focus on web chat and internet
forum interaction.
Kids Helpline
kidshelp.com.au
Kids Helpline is a free, private and confidential telephone and
online counselling service specifically for young people aged
between 5 and 25.
Lifeline Crisis Support
lifeline.org.au
Lifeline is a national charity providing all Australians
experiencing a personal crisis with access to 24-hour crisis
support and suicide prevention services. They also produce
and publish social policy submissions and reports, caller profile
reports, and research reports.
Butterfly Foundation (previously featured)

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2.4.8 TELEPHONE SUPPORT
A range of support lines are established, many relating to suicide support, pre and post incident.
Support After Suicide
supportaftersuicide.org.au
A service to allow users to connect and interact with
others who are also learning how to live with losing a
loved one. They provide information and resources, and
have counselling and group support directly for those
bereaved by suicide, as well as education and
professional development to health, welfare and education
professionals.
Suicide Call Back Service
suicideprevention.com.au
The aim of this service is to provide telephone counselling
to people aged over 15 years. This service caters to those
experiencing suicidality themselves, but also to carers,
people bereaved by suicide and professionals that are
caring for people affected by suicide. The Suicide Call
Back Service provides immediate telephone counselling,
but also up to six additional counselling sessions with the
same counsellor, scheduled at a time that suits the needs
of the caller.
AMWU Workers’ Union
amwu.org.au
AMWU Care is a free professional counselling service
available to Australian Manufacturing Welfare Union
members and their families 24 hours a day, seven days a
week.
ATAPS Suicide Support Line
ontheline.org.au/services/ataps-suicide-support-line
The ATAPS suicide support line is a specialised telephone
service designed to support allied health professionals
working with people at risk of suicide and self-harm. This
allows individuals to provide their clients with access to
dedicated professional telephone counselling. The service
is available 24 hours a day, seven days a week.

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Australia Post MensLine
mensline.org.au
Australia Post funds a dedicated support service, Australia Post
MensLine, as an integral part of their corporate health and
wellbeing program. The telephone counselling service provides
anonymous, confidential support for Australia Post employees.
Australia Post MensLine supports staff by promoting work-life
balance, and healthy work and family relationships. The service is
available nationally 24/7.
Department of Defence Triage Line
ontheline.org.au/services/department-of-defence-all-hours-
support-line
The All Hours Support Line is a confidential telephone referral
service for Australian Defence Force members and their families.
Funded by the Australian Defence Force, the line is primarily a
mental health triage service with the goal of linking serving
Australian Defence Force members to appropriate mental health
service providers. The service is available 24 hours a day, seven
days a week, ensuring accessible, professional support is
available whenever it is needed.
Veteransline
vvcs.gov.au/services/veterans-line.htm
Veterans Line provides free, professional, tailored support to
Australian veterans of war and peacekeeping operations and
their families. As the after-hours component of the Veterans and
Veterans Families Counselling Service (VVCS), Veterans Line
ensures 24/7 service provision for veterans and their families.
2.4.9 RECOVERY AND MUTUAL SUPPORT
BlueBoard
blueboard.anu.edu.au
BlueBoard is an online forum-based community for people
experiencing depression or anxiety, their friends and carers, and
for those who are concerned that they may have depression or
anxiety and want some support. We hope that this bulletin board
will enable people to reach out and both offer and receive help.

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2.5 POSITION
Old thinking is about creating a single gateway to resources and pushing traffic to that gateway. New thinking
is about embedding access to resources, not via one gateway, but rather within the online settings in which
people spend time.
Therefore, an effective and viable frontline response is about being able to serve people in whatever setting at whatever
time. Given that technology is ubiquitous, it is more than capable of facilitating access to these resources in these
settings, therefore e-mental health stands as a viable frontline response.
The COAG National Action Plan on Mental Health (COAG, 2006) determined that 20 percent of the population suffers
from mental illness (9-12 percent live with a mild illness, 4-6 percent moderate and the remaining 2-3 percent a severe).
While there have been many attempts at sizing the cost and burden of mental illness (Degney et al., 2012, Butterfly
Foundation, 2012, Medibank Health Solutions and Nous Group, 2013), none of these have adopted a holistic perspective
that encompass the dollar benefit of wellbeing as it relates to a defrayment of mental healthcare costs.
This chapter demonstrates that the current landscape is one of numerous, uncoordinated e-mental components that do
not work together as a single frontline response or as an easily navigable ecosystem of tools for self-management,
assessment and care.
Looking forward, in order for e-mental health to live up to its potential as a core component and leverage its comparative
advantage of cheaper reach, it must become an integrated system of care and the lead modality for frontline response
and early stage self management. In order to do this the online landscape must be led towards a coordinated and
integrated ecosystem that makes it simpler for consumers to access resources, manage their own care and access care
when needed.
This coordination and integration is best effected not through direct control but rather through a framework of
standards, integrations and sustainable business models that enable participants in this landscape to develop
interventions.
Where today there is a growing body of uncoordinated technologies, tomorrow there must be a core ecosystem of
technologies that work together and share data. Where today there is confusion as to where to go for help, tomorrow
there must be clear gateways that guide, assess and direct consumers. Where today there is narrow specific funding of
focused technologies, tomorrow there must be elimination of duplication and rigor in investment into the e-mental health
landscape.
As a frontline and assessment toolkit, e-mental health provides an excellent opportunity to increase reach at a low
marginal costs and efficiently reallocated cases to the modality that best balances expertise required, cost to society and
the individual needs of the consumer. Whilst we do not expect e-mental health frontline programs to reduce the cost of
the system overall, we do expect to gain greater value from the system.
As an early intervention or self management modality, e-mental health not only renders good Return on Investment (ROI)
it also delivers Social Return on Investment (SROI) as it presents the opportunity to deliver services to more people (its
reach to rural and remote is a clear example) in the prevention and early stages and keeping them as productive
members of society for as long as possible.
It is the position of this chapter that:
1. The total demand for mental health information and services outstrips supply.
2. Highly valuable clinical resources are being used to service conditions that could be self-managed.
3. There are proven resources available to help reduce the progression to mental ill health.
4. Increasing severity of conditions may be reduced through the introduction of self-managed care in between
face-to-face sessions.
5. There are some segments of demand that are not reachable by clinics, be they rural or remote, or vulnerable
populations.
6. Increasing capacity of the existing system for frontline and early stages is a flawed approach to addressing the
increasing demand for mental health services.

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2.6 MINOR RECOMMENDATIONS
1. Arrange and position all interventions in an ecosystem, so as to help people progress seamlessly through the
system, and prevent any individual getting “stuck” at one point.
2. Coordinate and enable the e-mental health landscape through the development of a national e-mental health
framework of standards and APIs. Such a framework is intended not to direct activity but rather enable e-mental
health participants to develop resources that add to the system of care and exchange data seamlessly.
3. Augment the national framework mentioned above with an approach to sustainable business models for use by
commissioners of e-mental health technology so as to ensure the ongoing viability of the initiatives beyond their
initial funding timelines. Without this unsustainable e-mental health components may require open-ended public
funding or be decommissioned, leaving gaps in the system.
4. Develop a national e-mental health register of e-mental health resources, so as enable funders to eliminate
waste and functional duplication, and enable e-mental health participants to re-use existing interventions before
developing duplicative ones. This would be populated through self-reporting, which is linked to funding.
5. Develop and promote a ‘tick’ or ‘certification’ advertised through a ‘powered by’ branding in order to give
consumers clear direction and access, as well as confidence in e-mental health components. This should be
promoted and displayed on all gateways and interventions. Key to achieving this ‘tick’ would be the requirement
to demonstrate that the intervention is evidence-based and can interoperate with other e-mental health
interventions.
6. Public funders of e-mental health interventions to require of their investees that all products adhere to the above
mentioned national framework; be developed in an open source manner, add to the system of care and do not
duplicate existing services.
2.7 SUPPORTING MATERIAL
2.7.1 CURRENT RESEARCH
A fundamental challenge for e-mental health is establishing the evidence for these opportunities at the same pace as the
rhetoric around potential opportunities.
The strengths and concerns around e-mental health are summarised by a recent rapid review by Lal & Adair (2014) that
covered 115 e-mental health articles published between 2000 and 2010, of which 51 percent were primary empirical
studies, and of this 22 percent were Australian.
Strengths
Concerns
Improved accessibility
Potential lack of quality control and standards
Reduced costs, following start-up R&D costs
Ethical and liability issues
Flexibility in terms of standardisation and
personalisation
Reluctance among some healthcare professionals /
"technological phobia"
Interactivity and consumer engagement
Worries that conventional services could be completely
replaced

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Considered especially promising for:
Rural populations
Individuals with barriers to access
People afraid of stigma
Youth
Some question the ability of professionals to establish
therapeutic relationships online and the feasibility of
online treatment for certain population groups (e.g.
patients with severe depression).
When considering the evidence presented for this table, particularly in view of the federal focus of this review, it is
important to consider Lal & Adair’s (2014) comment that:
“Most of the literature reviewed described the development, implementation, and evaluation of single
interventions in isolation. One very important question that has been given limited attention is how e-mental
health interventions might best be situated in relation to an array of related services for a broad population”. The
recent briefing paper for the Mental Health Commission of Canada (2014) also emphasises the importance of
integration
“Integrated properly, E-mental health is proving to be just as effective as face-to-face services … will result in
more people getting help [and] also improve the quality of care we deliver, reduce costs, and overcome
challenges that are present in our current health care system”.
Evidence to support the use of technologies for promotion and prevention in the Australian context includes:
• Strengths and concerns around e-mental health are summarised by a recent rapid review by Lal & Adair (2014)
that covered 115 e-mental health articles published between 2000 and 2010, of which 51 percent were primary
empirical studies, and of this 22 percent were Australian.
• The recent briefing paper for the Mental Health Commission of Canada (2014) emphasises the importance of
integration “Integrated properly, E-mental health is proving to be just as effective as face-to-face services… will
this result in more people getting help [and] also improve the quality of care we deliver, reduce costs, and
overcome challenges that are present in our current health care system”.
• Good evidence exists that technologies can be used effectively in improving mental health and wellbeing
(Cuijpers et al., 2008, Griffiths et al., 2010c), especially among young people (Christensen and Hickie, 2010b).
• An evidence-based literature review of over 50 studies examining young people's use of social networking
showed significant benefits to young people's mental health, including: delivering educational outcomes;
facilitating supportive relationships; identity formation; and, promoting a sense of belonging and self-esteem.
Collin et al. further argue that the "...strong sense of community and belonging fostered by SNS (social
networking services) has the potential to promote resilience, which helps young people to successfully adapt to
change and stressful events" (Collin et al., 2011).
• For those wishing to improve their overall wellbeing, technologies can assist in promoting social inclusion,
access to material resources and freedom from discrimination and violence (Burns et al., 2009)
• A very recent 2014 study by van der Krieke and colleagues, ‘e-mental health Self-Management for Psychotic
Disorders: State of the Art and Future Perspectives’(van der Krieke, 2014) found suggest that e-mental health
services are at least as effective as usual care or non technological approaches.
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2.7.2 EARLY INTERVENTION, ENHANCED SELF-MANAGEMENT AND SECONDARY PREVENTION STRATEGIES
E-mental health arguably makes the greatest impact in early intervention self-management and secondary prevention.
The goals of these strategies are not simply the reduction in immediate symptoms of distress but also a broader range of
more profound impacts including:
• Supporting ongoing participation in education and employment;
• Enhancing participation in relevant social networks and supporting age-appropriate social development;
• Reducing the risks of self-harm and suicidal behaviour;
• Reducing the risks of poor physical health through direct modification of relevant co-morbid risk factors such as
tobacco and cannabis smoking, as well as other lifestyle modifications such as enhanced physical activity,
management of appropriate eating behaviour and support for development of appropriate sleep-wake cycles;
and,
• Secondary prevention of development of alcohol and other substance misuse disorders.
This focus on earlier intervention during the teenage years has raised many conceptual, ethical and health service
challenges. From an illness-onset and treatment perspective, it requires active identification of disorders before they
necessarily reach current diagnostic thresholds — which in turn guide treatment selection. From an ethical perspective,
they raise questions about choice of treatment and potential exposure to harm associated with over-diagnosis, premature
medicalisation, of distress or over treatment.
From a health services perspective, traditional primary care services, and particularly those based in typical general
practice settings — see (Hickie et al., 2001) — have had the least engagement with the mental health concerns of young
people. Repeated mental health surveys in Australia have indicated the lack of progress between 1997 and 2007 in
attracting young people with mental disorders to healthcare — with only 16 percent of males under the age of 25 with a
mental disorder, and 30% of females, receiving professional assistance. This is despite the fact that young people
themselves increasingly recognise the importance of mental health problems emerging at this stage of life — and are
increasingly likely to seek help from peers, family and the internet (Burns et al., 2010b).
In response to recognition of the gap between the need for care and the use of traditional primary care services in
Australia, the national government supported the development of the headspace youth services network (McGorry,
2007). This network is based on the concept that healthcare can be delivered earlier in the course of the major anxiety,
mood, psychotic and substance misuse disorders if that care is targeted directly at young people and their families.
However, the capacity of centre-based headspace services or other more traditional primary care services to connect
with large numbers of young people, provide ongoing care or support, or focus on the broader range of outcomes
described above remains unclear. Importantly, as such services are conceived largely as short-term or crisis-focused,
they do not necessarily engage young people in the ongoing building of self-management supports or strategies or
ongoing monitoring of key aspects of both their physical or mental health. The opportunity, therefore, to link with more
dynamic e-mental health strategies is now perceived to be a major challenge for the field.

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3. Cognitive behaviour therapy
Australia has led the world in driving cutting edge research, which clearly shows that Cognitive Behavioural Therapy
(CBT) can be effectively delivered online, either self directed or with the support of a therapist. Australian research has
clearly shown that at a population and individual level online CBT can promote better mental health and deliver enhanced
mental health care (Christensen and Petrie, 2013; Griffiths, 2013; Proudfoot, 2013). Good evidence also exists that
technologies can be used effectively in improving mental health and wellbeing (Cuijpers et al., 2008, Griffiths et al.,
2010b), especially among young people (Christensen and Hickie, 2010b). Beacon collates online behavioural
interventions across over 40 conditions, including mental and physical conditions and provides a free guide to the
content and effectiveness of online behavioural interventions, mobile apps and internet support groups worldwide.
Developed and maintained by the Australian National University, the scientific evidence underpinning every application is
systematically reviewed according to best practice principles and a smiley-face rating system is used to provide users
with a guide to what works. Beacon also summarises the content, type and length of each intervention, its intended
audience, whether it is free or fee-based, the languages in which it is available and the findings of the research trials that
have investigated whether it works. A search of CBT on the Beacon website uncovered 10 pagers of online CBT
programs, many of which also include other therapies such as Dialectical Behaviour Therapy, Interpersonal Behaviour
Therapy and Mindfulness Therapy.
EXAMPLES
THIS WAY UP (thiswayup.org.au): Online treatment, education and research in anxiety and depression. THIS WAY UP
provides an online clinician assisted treatment program and provide information and technical training for clinicians.
Additionally there is a self-help program with guides to common mental disorders, psychological strategies and outcome
measures. An internet-based learning system that provides health and wellbeing courses for school students is also
available.
MindSpot Clinic (mindspot.org.au): Online assessment and treatment for anxiety and depression. Services can be
accessed online or via telephone for free and they also provide education and four to six week courses with access to a
MindSpot clinical resources.

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3.1 POSITION
THE DOUBLE-EDGED SWORD: WORLD CLASS RESEARCH BUT MISSING A STRATEGY
Considerable investment has been made in research and development regarding the provision of online CBT, this has
predominantly been funded in three ways, a) Government Departments (mainly Health, although other online CBT
approaches have been funded by Veterans and Defence, Social and Human Services, and Education); b) Research
bodies such as the National Health and Medical Research Council and the Australian Research Council, or, c) via third
party providers across the NGO, private and philanthropic sectors for example beyondblue, Movember, Telstra
Foundation, Sony Foundation, and so on. This substantial investment has placed Australia in an enviable position as a
world leader in e-mental health. It has also created a considerable ‘brains bank’ and technology infrastructure, including
advanced knowledge relating to managing data and responding to medico, legal and ethical considerations, across
Universities such as those at ANU, Swinburne University, the University of NSW, Griffiths University, Queensland
University of Technology, Melbourne University and Macquarie University (as examples, although there are research
pockets across all universities).
While innovation has occurred, this fragmented funding base has resulted in an extremely competitive environment
driven by funding cycles that are often short and have little or no focus on implementation or sustainability. In addition,
little thought has been given to strategic alignment with population need, and direction in relation to inclusion in existing
systems (such as schools, universities and workplaces), inclusion in other online settings (that is, embedded in social
networks or on other government portals such as mygov.com) or inclusion in current primary, tertiary or secondary health
care.
USER DESIGN AND HARD-TO-REACH POPULATIONS
The research regarding the provision of online CBT is very clear, it works. While there is less research evidence
regarding other therapies such as DBT, IPT or mindfulness therapy one would anticipate that taking other evidence
based therapies into the online environment should similarly translate and that they could also be delivered online, either
via self-directed websites or with clinician support. Despite having strong evidence that online therapies work much work
is still required to ensure that those population groups who are at most risk use them. This is particularly true for men,
young people, people living in regional, rural and remote communities and people who are indigenous, NESB and living
with a disability. Despite the fact that online modalities are confidential and available 24/7, the issues faced in primary
health care in relation to reach are mirrored in the online environment. Uptake is greatest for woman with most websites
reporting ratios of use of between 80/20 to 70/30. Critical to uptake and compliance is trust but also the concept of
‘stickiness’, that is what keeps an individual coming back. Increasingly, the principles of participatory design are being
introduced and UX design is becoming the norm in relation to build and rapid prototyping. It is becoming common
practice for researchers to work together with service providers and consumers to design, develop, implement and
evaluate online interventions. This approach also positions well for deployment via word of mouth as consumers have
ownership of the product.
Capacity for reach of self directed online therapy is high, particularly if delivered via schools, universities and workplaces.
COST EFFICIENCY: BETTER ACCESS VERSUS E-MENTAL HEALTH PROGRAMMES
In 2011 an evaluation of Better Access (Pirkis et al., 2011) showed that it reached 1.1 million people (one in 19 people in
the Australian population). While it was difficult for the evaluation to assess cost-effectiveness directly, findings show the
typical cost of a Better Access package of care delivered by a psychologist is estimated to be $753.31. Based on cost
modelling for optimal treatments for a population with common disorders, it is estimated that optimal treatment for anxiety
or depressive disorders costs about $1,100 in 2010 dollars. The evaluation also found that there are still some groups
who are not accessing the services they need. This is particularly the case with young people aged less than 15 years,
men, people living in rural and remote regions and people living in areas of high socio-economic disadvantage. Two-
thirds of people who used Better Access (65.5 percent in 2009) live in capital cities. Geographic disadvantage continues
to be an issue – compared to capital cities, people living in rural areas used the services 12 percent less and people
living in remote areas used the services 60 percent less. Additionally, people in areas of socio-economic disadvantage
are not using services at the same level as the broader population, with use of Better Access around 10 percent lower for
people living in the most socio-economic disadvantaged areas than in all other areas.

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A report prepared by the E-mental Health Alliance ‘e-mental health services in Australia 2014: current and future’ shows
that delivery of e-mental health is both cost-effective and cheaper to provide than care as usual (Hedman et al., 2012),
particularly for depressive and anxiety disorders. There is significant return on investment from e-mental health services,
which leads to improvements in both cost-benefit ratios and sustainability of care (Lokkerbol et al., 2014). For example,
a social return on investment study of Lifeline Online Crisis Support Chat service estimated a return of $8.40 for every $1
dollar invested in this service (netbalance, 2014). A cost-utility analysis of clinical trial data from the myCompass
programme for depression and anxiety shows that the programme can be delivered in a cost-effective manner, with a
cost per QALY gain of $3508 (unpublished data). This is approximately one fifth the cost of treatment with
antidepressants and a tenth the cost of recommended treatment with a psychologist to achieve the same QALY gain.
The E-mental Health Alliance also presents strong evidence, which supports the argument relating to the cost-
effectiveness, and lower overall expenditures of e-mental health in relation to other services arise:
• The low marginal costs of providing e-mental health services to individuals
• Volume savings as the number of patients treated increases
• Significant clinical improvement despite reduced, minimal or no therapist support, reducing per patient costs
while maintaining efficacy (Hedman et al., 2013)
• Reduced referrals to secondary mental health services and shortened waiting lists for face-to-face therapy in
primary and secondary care (Kaltenthaler et al., 2002)
• Use of lower cost non-clinical services for information, crisis support and peer support purposes, supplementing
the higher cost services as appropriate
• Additional benefits arising from immediate and unrestricted access to treatment, easier disclosure of sensitive
information, removal of the need to travel to a therapist, and availability of e-mental health programmes for
booster or revision sessions to prevent relapse.
Dissemination of e-mental health services can also potentially reduce demand on primary and secondary services and
lessen medication use and chronicity, leading to further reductions in the individual and societal cost burden.
Furthermore, recent overseas research into online preventive interventions reported that they have the potential to be
cheaper to implement than some treatment services, even before taking into account lost productivity due to illness
(Ruby et al., 2013).

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3.2 MINOR RECOMMENDATIONS
1. Map and integrate Australian online therapies into an “ecosystem of care”. The end goal should be
interoperability across all services which supports cross referral and pathways mapping, the generation and
reporting of outcome data, quality control and advice in the form of shared standards, safety protocols and
accreditation and incorporates and supports the ongoing nature of programme enhancements and technical
upgrades.
2. The Australian Government should explore co-investment and leveraged funding with University, NGO and
Industry partners to fund R&D innovation pipelines with a focus on sustainability via international growth and
sub licensing agreements of products.
3. Give priority to understanding the needs of population groups who are not using online CBT with existing
services tailored using the principles of participatory design, UX testing and rapid prototyping. This means the
inclusion of consumers and the resourcing of R&D to achieve maximum reach for hard to reach populations.
4. Prioritise dissemination and implementation immediately and give consideration to dissemination pipelines.
Areas that require further exploration:
• Quick wins such as making Beacon, MoodGym, THIS WAY UP and Mindspot available on large
portals such as MyGov.com and other gateway or crisis services such as Lifeline, Kids Helpline,
beyondblue, ReachOut.com and headspace.
• Tailoring offerings to make them relevant on other large platforms, quick wins could include
Movember, Facebook and the AFL.
• Online CBT packages created for schools, workplaces and universities.
• Via primary care and other health services such as hospitals and via referral by public and private
specialist mental health services (for example, allied health professionals and NGOs).
5. Primary health care providers should be educated about the provision of online CBT resources and incentivised
via Better Access to provide online CBT as the first line treatment option for mild to moderate depression and
anxiety. Explore the provision of iPads in surgery uploaded with Beacon, MoodGym, MySpot, THIS WAY UP,
with Airplay linked to the GPs. Simple fact sheet on online CBT resources via pharmacy guild, and so on,
General Practitioners (GPs) and eligible allied health professionals (for example, psychologists) includes
incentives to refer patients to low cost e-mental health services.
6. All Commonwealth funded mental health services are required to educate and make the public aware of e-
mental health services as an option available to them using consistent national messages. Together with direct-
to-the-public awareness raising initiatives, they will address the limited levels of e-mental health awareness in
the community, particularly in relation to the effectiveness and accessibility of e-mental health services and
empower consumers and families to seek them out or ask for a referral.
7. Training and education programmes for health professionals (such as e-mental health in Practice) are continued
in order to:
• build awareness of existing e-mental health programmes and services;
• develop systems that allow for successful incorporation of referral and follow-up into routine face-to-face
practice; and
• coordinate with organisations and professionals in community organisations (e.g. school counsellors), in a
staged approach to expansion.
8. Training and education programmes for non-health professionals are introduced to build awareness about self-
directed e-mental health programmes and establish systems for client referral to those programmes.

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3.3 SUPPORTING MATERIAL
• Online interventions for a range of mental disorders and problematic health behaviours (for example,
depression, anxiety, smoking, weight, substance use) have demonstrated efficacy, and the number of programs
available is growing rapidly (Mitchell et al., 2010).
• A review of 26 randomised controlled trials (RCTs) found the internet to be an effective medium for the delivery
of interventions designed to reduce the symptoms of depression and anxiety conditions in 88 percent of the
studies (Griffiths et al., 2010b).
• Calear and Christensen (Calear and Christensen, 2010) conducted a systematic review of internet-based
prevention and treatment programs for children and adolescents, identifying eight studies across schools,
primary health care, mental health clinics and via open-access websites. The authors concluded that the
"...findings provide early support for the effectiveness..." but more "...research is needed to further establish the
conditions through which effectiveness is enhanced" (p. S12).
• Tait and Christensen (Tait and Christensen, 2010) conducted a systematic review of RCTs of web-based
interventions for problematic substance use by adolescents and young adults. The authors identified 16 studies
largely from tertiary students and concluded that web-based interventions were as effective as brief in-person
interventions.
• While positive results are seen from the use of self-directed e-health interventions, there is some evidence that
these are most effective if used as part of a stepped-care model (van Straten et al., 2010), with the support of a
trained professional (Perini et al., 2009a, Titov et al., 2009a) or as an adjunct to face-to-face treatment (Hickie et
al., 2010).
• Bergström and colleagues (Bergström et al., 2010) demonstrated that internet-based cognitive behavioural
therapy (CBT) for panic disorder was equally effective as group-administered CBT treatment for adult patients in
an outpatient psychiatric care setting, while Gerrits and colleagues (Gerrits et al., 2007) found an online CBT
course for 140 adolescents with depressive disorders to have sustained and significant reductions in depressive
symptoms. Rotondi and colleagues (Rotondi, 2010) reported on the effectiveness of an online family psycho–
education program in conjunction with professionally–moderated patient and carer forums, which showed
improved engagement and education for patients with schizophrenia and their carers. Similar results for another
group of adults with schizophrenia were shown by Glynn and colleagues (Glynn et al., 2010). In addition, van
der Zanden and colleagues (van der Zanden et al., 2010) engaged a group of 48 parents with a mental illness to
demonstrate the effectiveness of an online group program to improving parenting skills.
• A more extensive study by van der Zanden and colleagues on the effectiveness of a web-based group course
for depression involving 244 adolescents and young adults between the ages of 16 and 25 years showed that
the online group course was effective in reducing symptoms of depression and anxiety and in increasing
mastery in young people. These effects were present in the initial review at three months and persisted in the
online course group at six months (van der Zanden et al., 2012).
• Other research indicates that information about depression and interventions that used cognitive behaviour
therapy and were delivered via the internet were more effective than a credible control intervention in reducing
symptoms of depression in a community sample (Christensen et al., 2004). The result of the study revealed
both cognitive behavioural therapy and psychoeducation delivered via the internet are effective in reducing
symptoms of depression (Christensen et al., 2004).
• In the development of the portal, Beacon, Christensen et al., conducted a systematic review and found
183 websites (up to March 2010), of which 122 focused on physical health or wellbeing, 40 targeted anxiety,
and 23 targeted depression. On a quality rating scale (with a score of two or more indicating evidence of
efficacy based on reports in the scientific literature) of the eight generalised anxiety disorder sites identified, four
achieved ratings of two or above. Two social anxiety disorder sites achieved scores higher than two. Ten panic
disorder sites were identified, with three achieving ratings of two or above; and five post-traumatic stress
disorder sites were identified, with two achieving ratings of 2 or above. Of the 23 identified depression sites, four

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achieved a rating of two or above (Christensen et al., 2010a).
• With permission, a number of tables have been repurposed for this review to showcase the evidence relating to
online mental health websites, many of which include principles of CBT, are automated online CBT or are
clinician assisted online CBT (see Appendix). The tables included are from a rapid review conducted for the
NSW Mental Health Commission (Burns, Hickie & Christensen, 2014) and a report “e-mental health services in
Australia 2014: current and future” which has been prepared by the E-mental Health Alliance representing a
core group of organisations listed to the right, who are currently providing highly effective and cost efficient e-
mental health services directly to the Australian population.

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4. Telehealth, telephone helplines and websites
As outlined in “The Case for Mental Health Reform in Australia”, mental health outcomes are sub-optimal and the current
system is comprised of a complex network of care settings and service providers, with mixed and overlapping
responsibility for information provision and service delivery between multiple government and non-government agencies.
The nature of mental illness also increases the likelihood that an individual will interact with multiple parts of the health
care system and the broader social services, yet the service model is fragmented and without coordination. This
fragmentation and lack of coordination is mirrored in the online environment.
The evolution of technology solutions for mental health
service provision has paralleled the development of
technology offerings and Australia has been at the forefront
of innovation. The idea of helping people by telephone was
the inspiration of Rev. Alan Walker, Superintendent of the
Central Methodist Mission in Sydney. In 1963 the first Lifeline
call was answered. Similarly, ReachOut.com was the worlds
first youth mental health website founded in 1997 by Jack
Heath with the intent of providing 24/7 access to support in a
confidential, safe environment, free of stigma. The initial
focus was on preventing suicide amongst young people living
in regional, rural and remote communities.
With the changing nature of technologies and a shift from
Web 1.0 (focused on information provision, one-way
communication and passive Involvement) to Web 2.0 sites
(collaborative, group participation, two-way communication,
active Involvement, user-generated content and blogging)
we have similarly seen a shift in mental health websites
from static information only sites to interactive
communication platforms where communities are built.
This chapter combines telehealth, telephone helplines and
websites as a clear delineation can no longer be made
between the three. For example Lifeline provides telephone
support to 820,000 callers per annum but also provides
online counselling to 40,000 clients. eheadspace provides
an information website which is accessed by 1.3 million
unique users per annum but also provide an online service
via eheadspace which provides telephone support to 40,000 young people each year, as well as providing online
counselling support via web enabled chat. ReachOut.com is built around the concept of an online community with 1.7
million unique users per annum accessing their resources and participating in the online peer moderated forums.

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4.1 POSITION
INTEGRATION AND IMPLEMENTATION
Given the utilisation of telephone helplines (Lifeline, Kids Helpline, beyondblue and eheadspace), the increased uptake
of online counselling (eheadspace, ED Hope, Lifeline), via web-enabled chat, a clear need for peer and family support
online (ReachOut.com and SANE) and the growing interest in research and development to support innovative mental
health professional service delivery (MindSpot, THIS WAY UP, Young and Well CRC e-mental health clinic) there is an
increasing realisation that consumers have different preferences for seeking help. Three issues are relevant and inform
the position of this chapter:
1. It is critical to ensure adequate pathways to appropriate care to ensure ‘right care at the right time’, this includes
direct triage to subject matter expertise (for example, Q-Life, Veterans Hotline, ED Hope);
2. It is paramount to reduce confusion about the service offerings available and creating a clear line of sight for
individuals about what is available for them, particularly in relation to their readiness for help seeking (see for
example, the Young and Well CRC Link project which brings together 14 sector providers);
3. Greater coordination of effort across service offerings is needed to ensure a seamless user experience, this
includes the creation of common standards and data sharing to ensure the individual only needs to tell their
story once (see Young and Well CRC Project Synergy).
Internationally, governments are increasingly considering some form of coordination and integration to ensure easy
access and consistent quality across the helplines and their websites. For example, in the United Kingdom, ‘Helplines
Partnership’ represents the helplines sector across the country and internationally. The integrated approach not only
leverages economies of scale while procuring and maintaining services but also facilitates coordinated improvement to
the services such as developing and issuing guidelines on confidentiality for all helplines across the UK. The agency is
funded by the UK Department of Health and is a good practical example of how central funding agencies can drive a
coordinated and integrated approach. Figures below show snapshots from search.helplines.org showing a range of
services that are offered by the Helplines Partnership to all its members.
Figure 12: Sub list of some of the helplines related to one subject (depression)

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Figure 13: Commonly shared services by the partner helplines
In New Zealand, the Ministry of Health has set up a National Governance Group to provide oversight of all Ministry
funded e-mental health initiatives under the National Depression Initiative (such as depression.org.nz and
lowdown.co.nz). The Ministry has also recently commenced the procurement process to develop and purchase an
integrated national telehealth service.
The New Zealand national telehealth service will include advice, support, assessment of symptoms, triage, treatment,
preventative (educational) and curative aspects of healthcare services. This new service is not about achieving a single
phone number but having services capable of ensuring, behind the scenes, whichever part of the National Telehealth
Service you contact is the front door able to get you to the right place and information. Various telephone numbers for the
individual service components can go into the same infrastructure. The national telehealth service will be free of charge
to users and available 24 hours per day, seven days per week either by telephone, text messaging or online. For the
public, the new national telehealth service will enable access to help and support via:
• Telephone triage, phone advice, support and counselling (single door access to Ministry funded helplines namely:
Healthline, Poisonline, Immunisation advice for the public, Quitline, Gambling Helpline, Alcohol and Drug Helpline
and Depression Helpline).
• Text messages
• Email communication
• Smartphone applications such as a symptom checker
• Health information available on the internet
• Online chat
• Self-guided e-therapy
• Social media including blogs and online forums
• Ability to refer to other health advice phone lines.
In summary, in Australia there is an opportunity for the funding agencies to consider coordinated and integrated
approach to helplines and websites to provide clear, coordinated high quality services to their users. Some of the options
include:
1. Setting up Governance Group to consider importance of diversity as well as to provide oversight and drive
coordination and ensure quality amongst various services, such as the Quality Framework for Telephone
Counselling and Internet-based Support Services group (2008).
2. Setting up a collaborative network or partnership framework amongst various services to leverage economies of
scale and work in collaboration, such as when headspace coordinated the National Online Telephone Support
Services, which bring together key youth services providers, Canteen, NCLYC and the Young and Well CRC.
3. Position Lifeline as the crisis and emergency helpline number, with sector engagement to ensure that calls can
be triaged and transferred to appropriate agencies or subject matter experts. This would similar to the role
played by Headspace in coordinating the NOTSS – National Online Telephone Support Services group which
brings together key youth service providers, plus Canteen, NCLYC and us as research partner, however it
would go beyond young people.
4. Establishing a system that facilitates long term partnerships between consumers and virtual service provider/s
to work together using cross disciplines, multi-modal communication (which may include one or more of texts,
emails, web updates, blogs and phone calls) to provide seamless and personalised healing experience
addressing a range of co-morbidities. For example, one patient needing help with depression, smoking and
alcohol abuse can be seamlessly assessed and supported rather than using different services for each
condition. This is consistent with the principles of participatory design and will become increasingly important as
different population segments are targeted.

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4.2 RECOMMENDATIONS
1. Mapping of information websites, telephone helplines, online counselling and peer and family support forums to
determine where there is true duplication and where there is the need for greater co-ordination. For example,
both eheadspace and Kids Helpline provide online counselling but it is not clear if this is duplication or rather
based on consumer choice, different needs or a true reflection of demand;
2. Improvements in the functioning of helplines across crisis support, subject matter and information only by
creating a more ‘joined up’ and collaborative model of service provision with each helpline playing its part
according to its expertise – and thereby reducing duplication and enabling the sharing of resources such as
technology systems, common protocols, standard measures and data sharing where possible;
3. The decision to regard Lifeline 13 11 14 as the national general crisis line and to provide a role for Lifeline
Australia to:
a. Coordinate with other helplines to develop referral protocols and pathways so that incoming callers can
be directed to appropriate services without having to navigate multiple phone numbers
b. Coordinate with emergency services and hospitals to explore potential referral protocols following
discharge of suicidal and mental health patients;
4. Recognition of the value of helplines in the overall ecosystem but with a clear understanding of how to triage to
greater support via online counselling or peer support forums and subject matter expertise;
5. Content (for example, fact sheets, digital campaigns, consumer stories) areas owned by content expert
organisations e.g. Butterfly Foundation with eating disorders, with some type of Content Management System to
allow cross sharing of resource; and
6. Greater attention should be given to the role of telehealth in Australia with a focus on up-skilling mental health
professionals, community awareness raising relating to its utility and mapping to determine greatest pockets of
need, that is indigenous, rural, regional and remote, disability support services.
4.3 SUPPORTING MATERIAL
This supporting material includes evidence from a confidential Australian rapid e-mental health review, material from the
Canadian E-mental Health Commission review and the tables used with permission from the E-mental Health Alliance
(see Appendix 2).
Given workforce shortages in mental health, the geographical and cost barriers to effective service provision, and the
reluctance of key groups (such as young people and men) to use formal clinical services, e-mental health innovations will
be central to real reforms (Rosenberg et al., 2009, Burns et al., 2013). Technologies are likely to have maximum impact
within the health system in the next decade if attention is given to both empowering individuals to use technologies to
manage their own mental health and wellbeing and integrating online services with face-to-face services. Currently, there
is a range of e-health strategies in place or early development to support early intervention, enhanced self-management
and secondary prevention (Christensen and Hickie, 2010a, Christensen and Hickie, 2010b).
The Australian Government uses the International Organisation for Standardisation definition of telehealth, which is
largely consistent with international usage of this term:
“Telehealth is the use of telecommunication techniques for the purpose of providing telemedicine, medical
education, and health education over a distance.”
— Department of Health, Australian Government (2012)

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There is further definition of ‘telemedicine’ as
“Telemedicine is the use of advanced telecommunication technologies to exchange health information and
provide health care services across geographic, time, social and cultural barriers.”
— Department of Health, Australian Government (2012)
While these definitions are broad in potential scope, there is a strong connotation that telehealth is primarily about
connecting patients with health practitioners, particularly doctors to provide a clinical service. For example, “it is about
transmitting voice, data, images and information rather than moving care recipients, health professionals or educators.
Video-conferencing is one of the main ways in which telehealth is improving access to healthcare services for patients
who live in regional, rural and remote areas.”
Gros et al., 2011 argues that telemental health, that is the provision of high-quality consultations to be conducted via
telephone or video conferencing via the internet, is increasingly gaining support in relation to home based
implementation (Gros et al., 2011). Telemental health consultations can encompass a range of services, such as
psychological assessment, diagnosis, care plan development, neuropsychological assessment, medication
management, forensic evaluation, psychological treatment, general guidance, psychoeducation and referral, and
management of psychiatric emergencies. When appropriate to aid in medication management, telemental health
consultation can be conducted in conjunction with a local general practitioner.
Telemental health can also involve provision of specialised training and/or supervision to clinical staff in remote locations
in the management of mental health conditions. Telemental health is often supported by email, or electronic medical
record transmission of supporting information.
Although telemental health has largely been implemented and studied in clinic settings, home-based telemental health
has growing support (Gros et al., 2011). The uptake of telemental health in Australia has been slow although Country
Health SA, the University of South Australia and Flinders University are exploring new models of tele-mental health
delivery in rural, regional and remote areas of South Australia. The Young and Well CRC with Brain and Mind Research
Institute at the University of Sydney are also exploring the use of telemental health for young people aged 16 to 25.
Numerous reviews of research conducted around the world have supported the use of videoconferencing technology for
evaluation and treatment of a wide array of mental health concerns in various populations (Chipps et al., 2012, Hilty et
al., 2013, Mohr et al., 2013). Diagnoses can be made reliably for children, adolescents, and adults and a wide range of
assessment scales have been shown to be reliable and valid when administered via synchronous telehealth systems.
Telepsychology and telepsychiatry have demonstrated feasibility and acceptability across populations with enhancement
of care through telemental health observed in subgroups of users (Chipps et al., 2012). Notably, satisfaction with
videoconference-delivered treatment has generally been on par with face-to-face treatment. In younger persons,
comparisons with in-person care suggest a preference for telemental health, resulting in greater satisfaction and superior
outcomes. In geriatric populations, telepsychiatry has produced satisfaction, diagnosis and outcomes metrics
comparable to in-person care, even for assessing and managing cognitive impairment.
In addition, telemental health has demonstrated feasibility veterans in the US (Gros et al., 2011) and with active duty
military populations in Australia (Wallace and Rayner, 2013). Having repeatedly demonstrated viability and acceptability,
telemental health is increasingly being utilised by population management healthcare systems around the world to
extend quality care to areas where it would otherwise not be available. Provision of mental health services to ethnically
and culturally diverse populations can be a particular challenge. Telemental health can help to overcome language and
cultural barriers by enabling provision of culturally sensitive services in patients’ native languages. In the US, cultural
adaptations of remote monitoring systems for veterans with PTSD have been successfully deployed with Native
Americans in remote locations (Brooks et al., 2012). Likewise, telepsychiatry has been shown to be a feasible means of
addressing the mental health needs of Indigenous people in Australia (Alexander and Lattanzio, 2009).
Overall, research suggests that telemental health can be an effective mode of delivery, and is no less effective than in-
person care. Randomised clinical trials have found comparable treatment outcomes for patients who received treatment
via videoconference compared to in-person delivery (Chipps et al., 2012, Hilty et al., 2013), with favourable results even
for challenging mental health problems, such as PTSD (Gros et al., 2011, Strachan et al., 2012). Telemental health has
also been shown to be a viable modality for delivering specific evidence-based treatments (Gros et al., 2011). Moreover,
teleconferencing can be an effective means of outreach, increasing help seeking among those reluctant to seek care,
such as college students (Haas et al., 2008). Support also exists for the feasibility, reliability, and validity of
asynchronous telepsychiatry, in which video and patient histories are uploaded for review by a remote psychiatrist who

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provides evaluation and recommendations to the primary care provider managing the patient’s care (Odor et al., 2011).
Finally, there is support for therapy delivered entirely via telephone and there are numerous examples of programs that
combine computer-guided intervention with telephone (Mohr et al., 2013).
More recently multimodal e-mental health interventions are being designed to enhance adherence and outcomes for
depression. The interventions include a combination of:
1. A website that requires frequent brief log-ins for self-monitoring and feedback.
2. Personal email support from a healthcare professional.
3. Brief telephone support guided by a theory-driven protocol.
The objective of these studies was to examine if internet intervention plus manualised telephone support program would
result in increased adherence rates and improvement in depression outcomes. The initial outcomes have been mixed
where some trials show limited additive advantage of telephone support by a lay telephone counsellor (Farrer et al.,
2013). Other studies showed significantly lower attrition rate by integrating web based interventions with telephone
support (as compared to either web based studies or trials of face-to-face interventions), and depression outcomes were
significantly better (Mohr et al., 2013). The findings indicate that the factors underpinning success of such a programme
might lie within:
1. The quality and engagement factor of the web based programme.
2. The skills of the person providing telephone support (a healthcare professional versus a lay counsellor).
3. The use of theory driven protocols rather than a free flow conversation.
MEDICO-LEGAL AND ETHICAL ISSUES AND ACCESS TO HEALTH PROFESSIONALS
While out of the scope of this paper, there are a number of pertinent medico-legal and ethical issues when considering
the utilisation of web-based support particularly in relation to data management, confidentiality and anonymity and duty of
care responses and a summation from the Canadian Mental Health Commission is provided in the Appendix. That said,
the sector has led ground breaking work particularly in the development of secure platforms for the suite of products
offered across ANU, Swinburne, UNSW, Macquarie, and so on, and the majority of concerns come from professional
bodies which fundamentally creates a barrier to the uptake of online support. Given that this is an emerging field,
particularly in the area of telemental health more work needs to be done in this area. A national standard is
recommended and this work has commenced through Project Synergy.

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5. Local initiatives
5.1 POSITION
When looking to learn from the international experience, it is important to remember that not all nations have
universal health care and within those, the understanding of a system of care for mental health varies. It is the
overarching position of this paper that Australia is very much the leader in this space and has been at the
forefront of international innovations in its use of e-health platforms to promote better mental health and deliver
enhanced mental health care (Christensen and Petrie, 2013).
From an Australian perspective, the Canadian experience is instructive. Both nations have large landmasses with
a few concentrated urban populations and many rural and remote communities. Both have indigenous population
issues to address and both have a similar basis to their economic value chains (for example, resources and
services with a modest manufacturing base).
Whilst there is a nationally funded institute Canadian Institutes of Health Research (CIHR), service delivery is left
very much to the provinces. This provincial approach was purportedly adopted to enable ‘local’ issues to be dealt
with by locals. As a result there is little or no publically federally coordinated and funded available mental health
care, and certainly none that is integrated.
In response to this, the private philanthropic sector (headed by the Graham Boeckh Foundation in Montreal) has
undertaken a project around the provision of community-led, youth-focused, service delivery which combines both
on and offline services. They consulted with headspace in Australia, Orygen Youth Mental Health Research
Centre and Orygen Youth Health, the Young and Well CRC and beyondblue to name a few. As a result they have:!
• Privately funded and commissioned a project to leverage on the experiences of these organisations in
the design of a clinical and online service model that can become national and publically available!
• Directed the design team for the online component of the above system, to liaise with the Young and
Well CRC locally so as to leverage on the technology model being deployed through Project Synergy!
• Instigated government to government discussions, and engaged with other key stakeholders, to
encourage the Canadian government to establish a leveraged fund model (much like the CRC program
locally) to continue to seed and deploy this integrated system of care.
In France, the UK and the US, e-mental health approaches have been characterised by a focus on one or more of
these three themes:
• The discourse around, or development of, an e-mental health record (in conjunction with or without an e-
health record)!
• The development, enhancement or even consolidation of telehealth services!
• Research, trial and deployment of specific technologies (websites and apps), by niche organisations to
address specific issues
There are a few successful initiatives internationally (for example, Samaritans, Big White Wall, headspace) but
again these are all point solutions, not complete approaches or models to e-mental health.
As outlined elsewhere in this report: !
• The current focus on an e-mental health record is about capturing transactional information and has
demonstrated little support from the sector and little relevance for consumers (see Chapter 7 below). The
world must move past the idea of translating all non-online activities into online activities. There is a
range of technologies being considered or deployed, just about all of which involve a web front end
(website, portal or app) to a cloud base On Line Transaction Processing (OLTP) based data store, which
itself is often an off shoot of a Departmental claims management system. Most of these solutions are
based on similar architectural principles, with the approach being an online emulation of a patient
transactional record.
• Globally there has been an explosion in both evidence based and non-evidence based wellness, health
and mental health apps and technologies as organisations seek to define themselves within the digital
context. In the e-mental health space a standout technology is the app eheadspace (not to be confused

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with the Australian clinical service provider headspace nor its telephone and internet support service,
eheadspace). Using standard web and app development technologies, this mixed fund solution has
gained significant international attention. It is however only a single solution and not a model.
• As the references below will indicate, academics, service providers and funders alike see the potential of
the e-mental health opportunity; the reality is that just about all except Australia are yet to begin the
journey on a systematic design and deployment of what an integrated model looks like, what technology
it sits upon and how it should be funded.
• As part of another assignment, the authors have undertaken interviews with over 25 leaders of mental
health service providers and researcher organisations globally, some private, but most publically funded,
and they have all, without exception, recognised the leadership position Australia holds in the design of
an e-mental health ecosystem as part of an integrated model of care. This leadership is recognised to
extend into:
− The selection of technology platforms and the use of technology in this space !
− The funding used to research, seed and deploy new solutions (combined public, private and
philanthropic alongside a leveraged funding model) !
− The global advocacy for more e-mental health based reform
5.2 RECOMMENDATIONS
The recommendations for this section are located in the Major Recommendations section above as they relate to
Australia continuing in its global leadership role and establishing a user centric integrated system of online and
offline care.
5.3 SUPPORTING MATERIAL
5.3.1 CANADA
Mental illness affects many Canadians, with one in five experiencing a mental illness in their lifetime. However,
young Canadians are the most profoundly affected, with 75 percent of mental health problems and illnesses
beginning prior to age 25, and more than 50 percent beginning between 11 and 25 years.
While young people are more likely to experience mental health disorders than any other age group, they have
the least access to mental health care. Existing services are designed for younger children and older adults,
meaning that the system is weakest where it should be strongest. As a result, mental illness takes an enormous
toll on youth and their families, with high levels of preventable mortality and lifelong illness.
In response, the Canadian Institutes of Health Research (CIHR) and the Graham Boeckh Foundation (GBF)
created the Transformational Research in Adolescent Mental health (TRAM) partnership to find solutions to this
problem and, ultimately, to improve mental health outcomes in Canada. TRAM has led to the creation of
ACCESS Canada – a research network that will seek to address this gap in care. It represents a new way of
working collaboratively with the provinces, territories, and partners, to increase resources and support research
that will transform Canada’s health care system.
ACCESS Canada will bring about transformational change in addressing adolescent and youth mental health and
wellbeing. By connecting patients and young people with researchers, health care professionals, and decision-
makers, the Network will bridge the gap between research evidence and health care practice and policy. It will
allow patients and families to benefit from research evidence by bringing the most promising interventions to the
front lines of health care.
Specifically, the objectives of ACCESS Canada are:
• to improve youth engagement and awareness of mental health issues leading to early identification of
those in need; and
• to make appropriate, evidence-informed, youth-friendly mental health care accessible to youth as early
as possible.

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This pan-Canadian initiative is the first-ever research Network launched under Canada’s Strategy for Patient-
Oriented Research (SPOR). SPOR is a coalition of federal, provincial and territorial partners – patients,
researchers, health care providers, and decision-makers – all dedicated to the integration of research into care.
This inaugural SPOR Network is being led by Dr. Ashok Malla, Director of the Prevention and Early Intervention
Program for Psychoses (PEPP-Montréal) at the Douglas Institute, Professor at McGill University and Canada
Research Chair in Early Psychosis.
Below are a number of support materials and references taken from the Mental Health Commission of Canada
(2014), of which Anil Thapliyal was a co-author. This information is used with permission.
5.3.2 EUROPEAN UNION
The role of e-mental health does not appear within the European Commission strategies for mental health, though
there is reference to: Digital Agenda, which includes a focus on ‘Living Healthy, Ageing Well’ where “information
and communication technology can be our most powerful ally for good and affordable
healthcare.” (https://ec.europa.eu/digital-agenda/node/1103)
The CORDIS division (Community Research and Development Information Service) have issued an ‘Information
and Communication Technology Challenge for Health, Ageing Well, Inclusion and Governance’ with “ICT for
Health activities” addressing ‘health management’ continuum from lifestyle to disease management, including
disease prevention and management of comorbidities
(http://cordis.europa.eu/fp7/ict/programme/challenge5_en.html)
Neither contains strategic frameworks relating to e-mental health.
5.3.3 NEW ZEALAND
New Zealand has had a similar pathway to Australia and has looked to Australia for guidance, with five to ten
years of investment in e-mental health services. This includes a more recent focus on developing strategic
context with the forthcoming publication of the New Zealand Government Ministry of Health’s Mental Health and
Alcohol and Other Drugs E-therapy Framework.
Key Document
Mental Health and Alcohol and Other Drugs E-therapy Framework (due 2014), issued by New Zealand
Government Ministry of Health.
Definition
New Zealand has taken a focus on e-therapies as a, “subset of e-mental health services that are primarily user
directed, computer system automated, and delivered online, or by mobile phone.”
Purpose
To provide an overarching framework for the planning, development, implementation, and investment in e-therapy
tools, interventions, programs, or products for use within mental health and alcohol and other drug (AOD) services
in New Zealand.
Aim
Provide guidance to the mental health and AOD sector on the key principles to be considered when planning and
developing or implementing e-therapy tools, interventions, programs, or products. It sets out a structure and
process for making informed investment and implementation decisions on Ministry of Health and/or District Health
Board commissioned e-therapy tools, interventions, programs or products.
There will be a Governance Group that will provide oversight of the Framework, and an approval process for e-
therapy tool and programs.

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Guiding Principles
• Must be evidence-based
• Must include routine evaluation
• Clinical governance in place
• Funding considered
• R&D component included
• Privacy Impact Assessment done
• Sustainability considered
5.3.4 UNITED KINGDOM
The United Kingdom recently published an e-mental health Discussion Document (2013).
Key Document
E-mental health, What’s all the fuss about? (2013) Issued by the National Health Service:
http://www.nhsconfed.org/Publications/discussion-paper/Pages/E-mental-health.aspx.
Context
The implementation framework for the No Health Without Mental Health strategy states that mental health
services should consider “the power of information to transform services” including “the potential of mental health
and wellbeing services that use technology to provide self-care and peer support within a well-governed, safe,
immediately accessible and stigma-free environment.”
The discussion document provides key areas for consideration, including governance, and key questions for the
future but does not recommend an integrated system of care. This is not an e-mental health strategy or blueprint.
5.3.5 UNITED STATES
The United States Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration (SAMHSA) has a Strategic Plan, which includes Health IT and Considerations for the Provision of
E-Therapy with a Substance Abuse focus.
Key Documents
Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014: http://store.samhsa.gov/product/SMA11-
4629.
Considerations for the Provision of E-Therapy (2009): http://store.samhsa.gov/shin/content/SMA09-4450/SMA09-
4450.pdf.
Both issued by SAMHSA.
Leading Change – Strategic Plan Outline The Leading Change document states that the Health IT Strategic
Initiative:
“Provides the overall framework… HIT is a broad construct that extends beyond Electronic Health Records and
includes telemedicine and other technologies. Health IT can improve health care quality, prevent medical errors,
increase administrative efficiencies, decrease paperwork, and improve patient health. It also has the potential to
enhance medical decision making, promote patient monitoring, and involve consumers in their own care.”
However, the objectives of this Strategic Initiative relate primarily to the use of Electronic Health Records.

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6. Potential gaps in e-mental health services in
Australia
6.1 POSITION
In Chapter 2, we discussed the positioning of many e-mental health interventions and explored areas of
duplication and potential gaps. In the Executive Summary, we provided a framework for the integration and
innovation of e-mental health interventions, which also provides a useful method for exploring this landscape
moving forward.
It is the position of this paper that the following holds in the service system:
• Lack of Coordination: Gaps in e-mental health must be identified and filled in a coordinated manner. The
lack of leadership and coordination at a time when a plethora of e-mental health technologies are being made
available to individuals is one of the glaring criticisms being levelled at the system. This position re-enforces
the recommendation above that a detailed blueprint of the e-mental health components of an integrated
system be developed.
• E-mental health is not a copy of face-to-face: There is a temptation to measure gaps in the e-mental
health service spectrum by comparing this to a traditional functional face-to-face service model. E-mental
health is not simply about the replacement or automation of face-to-face services. In fact it is the position of
this paper that in many cases, e-mental health is a complementary component of an integrated system of
care.
• Absence of a direction: The ability to identify a ‘gap’ is also based on having a clear view on the end-point
and being able to see what is needed to bridge this gap. A comprehensive view of the current state is missing
let alone a statement of the future or what the future state of an integrated system of care will look like.
• Degrading global leadership: When looking overseas for guidance on what is missing, it is clear that
Australia is in a leadership position with respect to e-mental health. Having said this, countries like New
Zealand and the United Kingdom have also made steps in turning their attention to e-mental health. New
Zealand is establishing a five to ten-year investment pathway into e-mental health and the United Kingdom
has published a discussion document on this topic (Mental Health Network, 2013).
• The gaps inside the services. Existing and proposed e-mental health services have many technology
layers. Gaps in services simply do not mean that a specific factsheet is not available or there is not an App
produced to help treat a specific issue. Software based technologies have subcomponents that have specific
tasks within the app, software or site. As is commonly understood, these are the Data layer, the Business
Logic layer, the User Experience (UX) layer and the Communications layer. Each layer is part of an e-mental
health service.
Using apps as an example, apps are attractive to users because, in part, their specificity enable them to
customise their mobile. A service in mental health terms, would require a combination of specific apps. In
order to make this work, the apps need to cooperate. If they don’t, there are gaps in the system. This is like
saying there are gaps at the cellular level of the e-mental health service system. This is a system wide gap in
e-mental health services. There is no consistency in UX, what works what doesn’t? At the data and
communications layers we do not yet have commonly agreed standards, protocols and application
programming interfaces (APIs) to enable interoperability between technologies so as to enable the
technologies to be arranged into a cohesive service or system.
• Universal Access – for some: The literature shows that people experience barriers in gaining access to
mental health services, with some segments of the population more underserved than others (Blanchard et
al., 2008b). Studies show that in Australia, many people lack access to traditional, clinic-based mental health
services (Christensen and Hickie, 2010a). Culturally and linguistically diverse (CALD) people experience high
levels of structural disadvantage that threaten their mental wellbeing as well as posing barriers to accessing
support (Francis and Comfoot, 2007). Exposure to trauma makes refugees especially vulnerable (Drew et al.,
2005). Other groups of people that face barriers to mental health services due to social exclusion,
discrimination, and other constraints include Indigenous communities; people living with disability or chronic
illness; carers; and sexuality, sex, and gender diverse people (Burns et al., 2008, Blanchard et al., 2008a).

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6.2 RECOMMENDATIONS
1. Ensure that the strategic blueprint of the integrated system of care, provides focused attention on gaps in
service delivery and care. This area is ripe for PPP with major organisations like Movember taking a lead
role in coordinating efforts around men’s health (as an example).
2. That barriers to access be considered a gap in the service. The ubiquity of the internet and the ease of
distribution of technology products, means that, for as long as there is the means to access the internet,
e-mental health can begin to bridge these access gaps. A specific policy should be to develop or extend
segments ‘beyond the digital divide’, data concession plans for use of e-mental health components etc.
6.3 SUPPORTING MATERIAL
6.3.1 FUTURE VIEW: USER JOURNEYS THROUGH AN INTEGRATED SYSTEM
Below are a number of vignettes designed to illustrate the journey of various individuals through an integrated
system of care. These user journeys were constructed with input from a variety of sector participants and have
also be extrapolated from interviews held. The key messages these user journeys tell are:
" An integrated system combines Telehealth, face-to-face services and online tools;
" Age, gender or location are not filters as to who would use which components of the integrated system
" The level of reliance upon the online or face-to-face components is dependent on the individual and the
stage of care they are at; and
" At each stage, the person’s information is able to be carried forward to the subsequent stage and, with
their permission, shared with the subsequent component (be that on or off line); this interoperability and
personal control is core to uptake.
4!
4
1.!PAUL’S MUM LISA SEES THE
HEADSPACE CAMPAIGN TO
PROMOTE HELP-SEEKING
FOR YOUNG MEN."
2.!LISA RECOMMENDS PAUL LOG
ONTO HEADSPACE.ORG.
USING THE LINK PLUG-IN,
PAUL IS DIRECTED TO HIS
LOCAL HEADSPACE SITE.
LINK PROVIDES RELEVANT
INFORMATION FOR
DOWNLOAD ON REFFERAL."
3.!PAUL AND LISA VISIT THE
HEADSPACE SITE TOGETHER
FOR PAUL’S ASSESSMENT BY
A CLINICIAN AND SHARE HIS
INFORMATION FROM LINK.
ASSESSMENT DETERMINES
PAUL NEEDS TO SEE A
CLINICAL PSYCHOLOGIST
FOR TREATMENT."
4.!WHILE WAITING FOR FIRST
APPOINTMENT HEADSPACE
DIRECTS PAUL TO SPECIFIC
APPS FOR YOUNG MEN ON
THE ONLINE WELLBEING
CENTRE."
5.!6 SESSIONS WITH A CLINICAL
PSYCHOLOGIST, ENHANCED
BY ACCESS TO DATA
(ENCRYPTED) FROM THE
APPS PAUL HAS BEEN USING."
6.!ONCE DISCHARGED FROM
CARE, PAUL JOINS HORYZONS
RECOVERY PROGRAM.
HORYZONS HAS ACCESS TO
DATA FROM LINK, ONLINE
WELLBEING CENTRE, APPS
AND HEADSPACE TO
SUPPORT PAUL’S RECOVERY."
// A USER JOURNEY THROUGH A SYNERGISED MENTAL HEALTH SYSTEM!
14-YEAR-OLD PAUL IN WESTERN SYDNEY "
WITH ANXIETY"
1. NATIONAL "
CAMPAIGN 2. HEADSPACE.ORG
WITH LINK PLUG-IN 3.HEADSPACE "
SITE VISIT
3. PAUL CHOSES TO
SHARE LINK DATA
(ENCRYPTED) WITH
HEADSPACE
4. PAUL ON THE
WAIT LIST PLUS
CONNECTED TO
ONLINE
WELLBEING
CENTRE
4. PAUL
DOWNLOADS
SLEEP WAKE
APP & SMILING
MIND
5. TREATMENT BY CLINICAL PSYCHOLOGIST,
ENHANCED WITH APPS PAUL HAS BEEN USING &
DATA. "
6. HORYZONS
RECOVERY
PROGRAM

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2!
2
1.!PORT PIRIE IS A YOUNG &
WELL TOWN. AT A SCHOOL
FORUM NICK HEARS ABOUT
KIDSHELPLINE."
2.!NICK LOGS ONTO
KIDSHELPLINE AND THE
COUNSELLOR SUGGESTS
HE REGISTER FOR ONLINE
WELLBEING CENTRE AND
DOWNLOADS THE
@PPRECIATE APP. "
3.!@PPRECIATE APP DIRECTS
NICK TO BUTTERFLY
WEBSITE WITH LINK PLUG
IN. THIS DIRECTS HIM TO
EITHER PORT AUGUSTA
HEADSPACE (AN HOUR
AWAY) OR THE ONLINE
MENTAL HEATLH CLINIC IN
PARTNERSHIP WITH
EHEADSPACE. "
4.!NICK CHOOSES THE
MENTAL HEALTH CLINIC,
DEVELOPS A 12 WEEK
SHARE PLAN WHICH HE
IMPLEMENTS WITH ONLINE
SUPPORT FROM A
MULTIDISCIPLINARY TEAM
WHO HAVE ACCESS TO HIS
DATA AND PLAN. HE ALSO
USES THE RECOVERY
RECORDAND RECHARGE
APP DURING TREATMENT
TO MANAGE EATING."
5.!AT THE END OF HIS 12
WEEKS HE IS REFERRED TO
HORYZONS ANXIETY
RECOVERY GROUP FROM
OYHRC.."
// A USER JOURNEY THROUGH AN INTEGRATED MENTAL HEALTH SYSTEM!
14-YEAR-OLD NICK IN PORT PIRIE, SA"
WITH EATING AND SLEEP CONCERNS"
#
"
1.!YOUNG AND WELL
SCHOOL FORUM 2. SINGLE SIGN ON
REGISTERS ON OWC"
& DOWNLOARDS APPS
3. SSO BUTTERFLY
WEBSITE WITH LINK
PLUG IN DIRECTS NICK
TO….
4. HEADSPACE IN PORT
AUGUSTA OR ONLINE
PROFESSIONALS
CLINIC
@PPRECIATE
APP (SSO)
DIRECTS NICK
TO BUTTERFLY
FOUNDATION
4. 12 WEEK SHARE
PLAN INCLUDING
SHARING DATA FROM
HIS APPS
4. USES RECOVERY
RECORD AND
RECHARGE
5. REFERRAL TO
HORYZONS ANXIETY
RECOVERY GROUP
1!
1
1.!SALLY CALLS LIFELINE AND
BECAUSE SHE DESCRIBES
ISSUES WITH EATING IS
TRIAGED TO ED-HOPE."
2.!THE ED HOPE COUNSELLOR
DIRECTS SALLY TO ED
EXPERT AND TO
HEADSPACE IN GEELONG
FOR ED SERVICES SUCH AS
AN IOP"
3.!ED HOPE COUNSELLOR
ALSO RECOMMENDS NEDC
& REACHOUT.COM"
4.!SALLY PRINTS
INFORMATION TO TAKE TO
HER ED EXPERT AND
HEADSPACE VISIT. "
5.!ED HOPE AND ED EXPERT
RECOMMENDS THE
GEELONG CLINIC WITH A
SPECIALIST TRAINED IN
USING TECHNOLOGY AS AN
ADJUNCT TO CARE"
6.!SALLY DEVELOPS A 12
WEEK SHARE PLAN WHICH
SHE IMPLEMENTS WITH
ONLINE SUPPORT FROM A
MULTIDISCIPLINARY TEAM
INCLUDING ED HOPE WHO
HAVE ACCESS TO HER DATA
AND PLAN. "
7.!SALLY USES THE
RECOVERY RECORD APP
WHICH PARTNERS WITH ED
HOPE AND RECHARGE
DURING HER TREATMENT
TO MANAGE HER EATING."
8.!SALLYS CARE PLAN IS
FURTHER SUPPORTED WITH
APPS AND ONLINE CBT TO
MANAGE ANXIETY."
// A USER JOURNEY THROUGH AN INTERGRATED MENTAL HEALTH SYSTEM!
25-YEAR-OLD SALLY IN GEELONG"
WITH AN EATING DISORDER"
#
"
1.!SALLY CALLS LIFELINE AND
IS DIRECTED SPECIALIST
ADVICE AT TO ED HOPE
2. THE ED HOPE
COUNSELLOR
DIRECTS SALLY TO
HEADSPACE IN
GEELONG
4. SALLY PRINTS
INFORMATION TO TAKE
TO HER HEADSPACE
VISIT.
5.. HEADSPACE GEELONG
RECOMMENDS THE
GEELONG CLINIC WITH A
SPECIALIST TRAINED IN
TECHNOLOGY AS AN
ADJUNCT TO CARE
3. ED HOPE
COUNSELLOR
RECOMMENDS
NEDC &
REACHOUT
WEBSITES
6. SALLY PREPARES A
12 WEEK SHARE PLAN
INCLUDING SHARING
DATA FROM HER APPS
7. SALLY USES
RECOVERY RECORD
AND RECHARGE
8. SALLYS CARE PLAN IS
SUPPORTED WITH APPS
AND ONLINE CBT TO
MANAGE ANXIETY

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3!
3
3
// A USER JOURNEY THROUGH AN INTEGRATED MENTAL HEALTH SYSTEM!
60-YEAR-OLD !
JOHN IN BROKEN HILL WITH DEPRESSION"
1.#JOHN SEES ADVERTISING FOR
BEYONDBLUE’S
MANTHERAPY CAMPAIGN."
2.#JOHN LOGS ONTO
MANTHERAPY.ORG.AU AND
WATCHES A NUMBER OF
VIDEO TESTIMONIALS
DETAILING PERSONAL
EXPERIENCES WITH MENTAL
ILLNESS."
3.#JOHN DECIDES TO SIGN UP TO
THE ONLINE DISCUSSION
FORUM OFFERED BY SANE,
VIA THE MANTHERAPY
WEBSITE, WHICH ALSO
RECOMMENDS JOHN VISIT HIS
GP. "
4.#USING THE INFORMATION
COLLECTED FROM THE
ONLINE DISCUSSION FORUM,
JOHN’S GP REFERS HIM TO A
CLINICAL PSYCHOLOGIST.
WHILE WAITING FOR HIS
FIRST APPOINTMENT HE IS
DIRECTED TO BEACON AND
USES THE ONLINE
RESOURCES."
5.#6 SESSIONS WITH A CLINICAL
PSYCHOLOGIST ARE
ENHANCED BY ACCESS TO
DATA (ENCRYPTED) FROM THE
APPS AND ONINE TOOLS
JOHN HAS BEEN USING
WHICH FEED INTO HIS SHARE
PLAN."
6.#JOHN ALSO JOINS A LOCAL
MENS SHED PROGRAM. HE
CONTINUES TO MONITOR HIS
MOOD AND ACTIVITY USING
APPS IN HIS SHARE PLAN.. "
1. NATIONAL "
CAMPAIGN 2. LOGS ONTO
MANTHERAPY
3. SIGNS UP TO ONLINE
DISCUSSION FORUM
4. DOWNLOADS APPS
FROM BEACON
5. 6 SESSIONS WITH A
CLINICAL PSYCHOLOGIST
ENHANCED WITH A SHARE
PLAN
6. JOINS A LOCAL MENS
SHED PROGRAM AND
CONTINUES TO MONITOR
HIS MOOD VIA A
WELLBEING PLAN
5!
5
// A USER JOURNEY THROUGH A SYNERGISED MENTAL HEALTH SYSTEM!
35-YEAR-OLD JILL IN COFFS HARBOUR WITH !
ALCOHOL AND SUBSTANCE ABUSE ISSUES"
!
1.#JILL SEES THE BLACKDOG
INSTITUTE CAMPAIGN TO
INCREASE MENTAL HEALTH
AND WELLBEING LITERACY
IN ABORIGINAL AND
TORRES STRAIT ISLANDER.!
2.#USING LINK ON HER
MOBILE, JILL IS DIRECTED
TO THE ONLINE WELLBEING
CENTRE. SHE IS
RECOMMENDED TO USE
THE IBOBBLY APP, A
PROGRAM SPECIFICALLY
AIMED AT COMBATTING
SUICIDAL IDEATION IN
INDIGENOUS YOUNG
PEOPLE. THIS ALLOWS HER
TO ACCESS HELP
CONFIDENTIALLY AND IN
HER OWN TIME.!
3.#VIA LINK AND USING DATA
COLLECTED USING
IBOBBLY, JILL IS THEN
REFERRED TO A LOCAL
EMPLOYMENT SERVICE AND
IS SCHEDULED TO CHECK
IN WITH A YOUTH WORKER
ONCE-A-WEEK TO MONITOR
HER PROGRESS.!
4.#JILL USES RECHARGE, A
MOOD AND SLEEP APP TO
MONITOR HER DAILY
ACTIVITY, AND TO HELP
ADDRESS HER ISSUES WITH
ALCOHOL SIGNS UP FOR A
HELLO SUNDAY MORNING. !
1.#THE BLACKDOG INSTITUTE
NATIONAL CAMPAIGN
2. ONLINE WELLBEING
CENTRE
3. REFERRAL TO EMPLOYMENT
SERVICE AND REGULAR
APPOINTMENTS WITH YOUTH
WORKER ARE SCHEDULED
4. MONITORING OF
MOOD AND SLEEP
AND SIGNING UP
FOR A HELLO
SUNDAY MORNING

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74
6.3.2 BARRIERS TO ACCESS, THE DIGITAL DIVIDE AND THE ROLE OF TECHNOLOGIES
It is beyond the scope of this document to showcase the barriers to access to high quality care. This was
adequately covered in Adjunct Professor John Mendoza’s document “Obsessive Hope Disorder”, which included
the collective knowledge of the sector both current and historical.
The following literature is taken directly from the NSW Mental Health Commission review and while technologies
have been discussed in the context of reducing disparities in access to care it is still very clear that the issues and
challenges in in face-to-face service offerings are similar in the online environment. The following literature is
heavily weighted towards young people. Areas requiring greater attention include the lack of help seeking by men.
In the youth mental health space Young and Well CRC, ReachOut.com, Brain and Mind Research Institute and
Headspace and Orygen Youth Health Research Centre have prioritised young men’s mental health and have
committed significant resource to understanding the structural, cultural and individual challenges for this particular
demographic. This has been strongly supported by Movember. Similarly, Suicide Prevention Australia is leading
an alliance of the sector with a major focus on the prevention of suicide in men.
The disadvantage experienced by Indigenous Australians living in remote communities is a factor in higher rates
of serious mental disorders and of mental health problems that are compounded by narrowly focused and
inadequate mental health services, with children being particularly vulnerable (Hunter et al., 2007). Socio-
economic factors also play a role in determining access to care, with young people living in disadvantaged areas
more likely to lack social support (Australian Institute of Health and Welfare, 2007).
A number of different types of barriers faced by Australians in need of mental health services were indicated by
the literature. For example, geographical barriers can limit access to services for people too young to drive,
particularly in rural and remote locations where public transport is not (Aisbett et al., 2007, Boyd et al., 2007).
Physical constraints can prevent access for people living with disability and chronic illness (Burns et al., 2008).
Cultural barriers, such as language and communication difficulties, can complicate service access for Indigenous
and CALD youth (Gorman et al., 2003). Temporal barriers have also been suggested by research, as young
people are more likely to experience psychological distress after 11pm when mental health services are less
available (Burns et al., 2013).
6!
6
1.!HEADSPACE NATIONAL
CAMPAIGN TO PROMOTE
HELP-SEEKING FOR YOUNG
MEN."
2.!PAUL LOGS ONTO
HEADSPACE.ORG WITH
LINK PLUG-IN & SUGGESTS
HE VISIT HIS LOCAL
HEADSPACE SITE. LINK
PROVIDES RELEVANT
INFORMATION FOR
DOWNLOAD ON REFFERAL."
3.!PAUL VISITS HEADSPACE
SITE FOR ASSESSMENT BY
A CLINICIAN AND SHARES
HIS INFORMATION FROM
LINK. ASSESSMENT
DETERMINES PAUL NEEDS
TO SEE A CLINICAL
PSYCHOLOGIST FOR
TREATMENT."
4.!WHILE WAITING FOR FIRST
APPOINTMENT HEADSPACE
DIRECTS PAUL TO SPECIFIC
APPS FOR YOUNG MEN ON
THE ONLINE WELLBEING
CENTRE."
5.!6 SESSIONS WITH A
CLINICAL PSYCHOLOGIST,
ENHANCED BY ACCESS TO
DATA (ENCRYPTED) FROM
THE APPS PAUL HAS BEEN
USING."
6.!ONCE DISCHARGED FROM
CARE, PAUL JOINS
HORYZONS RECOVERY
PROGRAM. HORYZONS HAS
ACCESS TO DATA FROM
LINK, ONLINE WELLBEING
CENTRE, APPS AND
HEADSPACE TO SUPPORT
PAUL’S RECOVERY."
// A USER JOURNEY THROUGH AN INTEGRATED MENTAL HEALTH SYSTEM!
12-YEAR-OLD PAUL "
IN ADELAIDE WITH ANXIETY"
1. NATIONAL "
CAMPAIGN 2. HEADSPACE.ORG
WITH LINK PLUG-IN 3.HEADSPACE "
SITE VISIT
3. PAUL CHOSES TO
SHARE LINK DATA
(ENCRYPTED) WITH
HEADSPACE
4. PAUL ON THE
WAIT LIST PLUS
CONNECTED TO
ONLINE
WELLBEING
CENTRE
4. PAUL
DOWNLOADS
SLEEP WAKE
APP & SMILING
MIND
5. TREATMENT BY CLINICAL PSYCHOLOGIST,
ENHANCED WITH APPS PAUL HAS BEEN USING &
DATA ."
6. HORYZONS
RECOVERY
PROGRAM

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75
Digital connectivity has been affirmed as increasingly important, particularly for young people. For this reason it is
important to consider the role of technologies in achieving greater levels of health equity, as well as the inequities
generated by barriers to access to technologies, known as the 'digital divide'. Access to the internet has been
linked to income, class, ethnicity, disability status, and levels of education (Notley and Foth, 2008, Livingstone
and Helsper, 2007, ABS, 2008). Metropolitan families with children under 15 years of age in higher income
brackets are more likely to use computers and the internet, while groups that are less likely to have access are
Indigenous Australian, the unemployed, people with low incomes, and people living with a disability (Notley and
Foth, 2008).
The literature suggests that removing barriers to internet access can be useful in improving mental health
outcomes for young people. In addition to the barriers young people face in accessing mental health services,
young people with mental health problems are less likely than adults to seek help from GPs or clinic-based
services (Blanchard, 2011, Collin and Burns, 2008). Recent studies demonstrate that young people prefer to
access support online (Gould et al., 2002, Hampshire and Di Nicola, 2011, Burns et al., 2010b) and that online
services can transcend many of the barriers faced by traditional clinical services, such as temporal and
geographical constraints. This research, combined with recent policy documents (Christensen et al., 2010b),
present a strong case for the potential role of mental e-health services in improving both access to services, and
rates of usage by young people (Burns et al., 2010a).
A better understanding of how young people access support through the internet is important when considering
how to improve equity of access and reduce the digital divide. One Australian study found that 43 percent of
young people at greater risk of mental health problems accessed the internet at home, with libraries (32 percent),
schools (18 percent), internet cafes, workplaces, and youth centres cited as other points of access (Blanchard et
al., 2008). Studies in the US and Germany have found evidence of increased access to the internet through
mobile phone usage in disadvantaged populations of young people, indicating the importance of mobile phone
applications (Thomas et al., 2010, Horrigan, 2009).
The use of social media to bolster social inclusion is also indicated by a study that found 57 percent of young
people creating online content using Web 2.0 platforms in the US belong to racial minorities (Lenhart and Fox,
2006). Recent reports show that 90% of Australians aged 12 to 17 use social networking sites frequently, with
figures increasing to 97 percent when only 16-17 years olds are considered (Australian Communications and
Media Authority, 2009). Further research undertaken with young Australian men reported that those suffering from
psychological distress were significantly more likely to seek mental health information through the internet, with 95
percent reporting that they were satisfied with information they received (Burns et al., 2013).
6.3.3 TECHNOLOGY AND FUNDING TO ADDRESS WORKFORCE CHALLENGES
Youth health workers believe that using technologies will enable them to have a greater impact on young people's
mental health, argue Blanchard and colleagues (Blanchard et al., 2012). The same study reports that youth health
workers believed that technologies play a considerable role in the lives of most young people, and that these
technologies have the potential to influence mental health and wellbeing, both positively and negatively. However,
participants also felt that these technologies are poorly understood and under-utilised in mental health promotion
and in the prevention, early intervention and treatment of mental ill-health.
If barriers to the use of technologies were overcome, the youth mental health workforce would be able to use
technologies more effectively in their practice. Such barriers include poor infrastructure, lack of guidelines or
policies to support safe and constructive use of technologies and lack of awareness about which technology-
based strategies or approaches are most effective, and in which contexts (Blanchard et al., 2012).
Further investment needs to be made in securing appropriate technological infrastructure in youth mental health
services, and in training staff members to develop an adequate understanding of young people's technology use
and the range of strategies that can be applied to improve and promote young people's wellbeing (Blanchard et
al., 2012). The capacity of the existing health workforce to integrate e-mental health services into their practice
has been found to be low. Funding, promotion, professional development and online teaching resources have
been needed to increase uptake and sustained use.

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76
7. E-mental health records
7.1 POSITION
The current Personally Controlled Electronic Health Record (PCEHR) has been met with limited success. Low
uptake due to lack of awareness and unclear benefit of use do not incentivise end users to sign up to the system.
In fact, there is little additional functional benefit than digitising the paper system.
The promise of better diagnosis and information sharing across locations is countered by the limited utilisation
and uptake by doctors, many claiming workload, lack of structural technology supports and challenges relating to
medico, legal and ethical considerations. Particularly when considering the use of the PCEHR in the management
and support of those living with a mental illness, significant duty of care issues need very careful consideration.
Specifically, issues requiring careful consideration include the duty of care to intervene if the system detects
scenarios such as one person getting multiple prescriptions from multiple locations or poor quality care,
misdiagnosis or compromised treatment.
This lack of clear value proposition, coupled with unincentivised data entry and history review, make it unlikely
that more medical professionals or end users will adopt the current system.
As a result of a recent review, 38 recommendations for improvement have been made, however the Department
of Health maintains that it will take four years for these to be implemented. Considering this considerable timeline
(not to mention investment) it is the position of this paper that emerging technologies will supersede this initiative,
with individuals’ data from multiple sources “talking to each other” through interoperability and augmenting face-
to-face care.
7.2 RECOMMENDATIONS
1. Based on low uptake in international deployments of electronic health records, a fundamental rethink of
purpose and design would need to be undertaken before establishing an e-mental health version. This
exercise should include participatory design principles, wherein the end user is involved to ensure that the
service being developed was actually meeting a real need. If the ecosystem and standards recommended in
this paper are developed, this technology makes the need for such an e-mental health record redundant, as
data from different applications will integrate and provide real-time data and history, which individuals can
use to gain a holistic perspective of their mental health and wellbeing, and which they can choose to share
with professionals if they so wish to support their face-to-face care.
7.3 Supporting Material
The Personally Controlled eHealth Record (PCEHR) is described from ehealth.gov.au as
“An electronic summary of your health records that individuals and authorised healthcare providers (such
as doctors, nurses and other staff) can access it online, including information like medications, hospital
Discharge Summaries, allergies and immunisations.”
Its existence is supported by the Personally Controlled Electronic Health Records Act of 2012.
The PCEHR is free, voluntary, federal and is additional to existing health records held by health providers. People
who choose to use it are required to register themselves using an authorised identity, i.e. anonymity is not an
option. Patients and their clinicians usually decide together what data are made available in the PCEHR but this
process is probably used inconsistently among clinicians depending on the nature of the clinician-patient
relationship.
The 2013 review on the PCEHR progress (2013) provides 38 recommendations. The following recommendations
have implications for e-mental health.

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77
• Restructuring governance has implications and opportunities to include stronger representation for e-mental
health (recommendation 2).
• Establishing a clinical and technical advisory board, offers opportunities to progress e-mental health as a
priority (recommendation 3). This aligns with recommendation 11 and implies that centralisation of EHR
services (and by extension mEHR) can be facilitated and supported centrally.
• The new task force for the governance transition offers opportunities for e-mental health to be overtly
included in the transition (recommendation 4).
• Regulation of e-health standards implies that e-mental health standards require inclusion, resulting in
opportunities for development of standards that may apply only to e-mental health (recommendation 10). This
aligns with recommendation 32. Implications of the PCEHR on mental health range from interoperability
between the PCEHR, the electronic health records (EHRs) that feed it, and the ability to make Internet-based
tools, e.g. MoodGym, iSpot interoperable with either the PCEHR or existing versions of EHRs. Policy
decisions about the potential to link Internet-based tools to something like the PCEHR have yet to be
explored.
• The transition to the ‘opt out’ model (recommendation 13) may impact on people’s desire for anonymity, and
therefore influence approaches to privacy in e-mental health services. While patients will be able to decide to
not make certain records available, the PCEHR (or MyHealthRecord as it will be called in the future) draws
from data repositories, e.g. medications that could reveal information that patients may not want revealed.
• The PCEHR architecture is complex – people with mental health issues may find it harder to use than other
people, as found by MyHealthyVet users (Rice et al., 2013). The minimum composite of records in
recommendation 21 indicates inclusion of medication lists, which could in turn reveal mental health
diagnoses by clinical deduction that patients may not want to occur. Adding a flag to notify clinicians of
restricted information (recommendation 27) may benefit the clinician’s decision-making process for diagnostic
purposes but may impinge on patient privacy when a ‘break glass’ rule is used.
• Privacy and security in mental health environments are considered more sensitive than for other health
issues, while new concerns about, for instance, genomic testing are emerging in the privacy debate, i.e.
mental health data is not the only sensitive data in the record but does deserve consideration in light of the
vulnerability of people with mental health issues (McGuire et al., 2008, Craig et al., 2014). Recommendations
15 and 16 could benefit from mental health representation on the recommended committees and working
groups.
• Secure messaging facilities in the PCEHR (recommendation 24) could be leveraged for e-mental health
services, but would be subject to policy regarding the use of secure messaging between patient and clinician,
thus limiting e-mental health messaging to additional interoperable software products. The growth of mobile
apps and other technologies with potential to provide a range of services with or without the patient-clinician
relationship (Klasnja and Pratt, 2012) plus the potential of the Quantified Self for prevention, self-care and
intervention models of care that don’t yet exist (Swan, 2012) may influence the scope of message facilities in
the PCEHR in the future.
• Notifying patients whenever their records are opened (recommendation 28) may be counterproductive with
some patients. People who use mental health services also use other services, and are often frequent users
with comorbidities, making them more vulnerable than the majority of healthcare consumers (Rivers, 2010).
How multiple notifications are delivered over time should be considered, especially if telephone and website
access is part of the PCEHR notification system.
• Recommendation 30 talks about evolving education on how to use the PCEHR. This has implications on
website and telephone service providers in terms of linking their services to the PCHER, as well as informed
consent for patients who give them access to enable service delivery. As pointed out by Rice et al (Rice et
al., 2013) the more compromised one’s mental health is, the harder it is to use PHRs. Education programmes
should deliver to a wide range of health literacy competency.

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Figure 14: PCEHR statistics reported as at midnight 1 September 2014
The uptake of the PCEHR is low, which is in keeping with the uptake of Personal Health Records (PHRs) in
general (2013, Nazi, 2013). Up to 80% of general practices have enrolled but only 10% are contributing records to
the PCEHR (Craig et al., 2014). PHRs work best for people when the features allow them to do more than view
content, e.g. transactional activities such as make appointments, order repeat prescriptions and have brief written
communications with their doctor (Day and Gu, 2012).
Mental health records are not usually specifically kept separate from general health records, other than as a
function of authorised access. They are usually recorded in the same software/database that serves an
organisation, and are separated by means of user profile rather than software ring-fencing. Services provided
online are usually separate from a healthcare organisation’s information system. Interoperability would be the
biggest technical barrier to integration. Clinical processes and clinician attitudes to Internet-based mental health
services would be the biggest organisational challenge for integration, with psychiatrists least likely to use EHRs
than other clinicians (Druss and Dimitropoulos, 2013).
International attempts at including mental health features in PHRs include:
! MyHealthyVet (US). Veterans appear to be willing to use the service but the numbers of actual users is
small (Tsai and Rosenheck, 2012). Rice et al (Rice et al., 2013) outline the difficulties people have
accessing mental health services (lower insurance funding than for physical health issues, stigma and
stereotyping of people with mental health issues) and use MyHealthyVet as an exemplar ePHR.
! HealthSpace was rolled out in the UK but has closed down. Greenhalgh et al (Greenhalgh et al., 2010)
outline the reasons for non-adoption.
! Estonia, Spain (particularly Andalucia), Netherlands, Denmark, Sweden and Germany all have versions
of PHRs but the literature is mostly silent on mental health as a component.
A large body of literature is emerging on PHRs in general. Kaelbar et al (Kaelbar et al., 2008) describe a research
agenda in which researchers focus on functionality evaluation (without specifying mental health), privacy and
security, adoption and attitudes, and PHR architecture. The literature is grappling with the basics at the moment,
with some reference to mental health issues, e.g. Rice et al.’s comments about barriers being exacerbated by
mental health issues.
The PCEHR (and PHRs in general) is not yet mature. It was implemented in July 2012 and uptake is low and
slow. The recent review has 38 recommendations, many of which influence one another, and each of which
demands considerable attention and effort in response. As pointed out by Kaelbar et al. (2008), the research
agenda is still new. Mobile technologies (include phones, websites and apps functionalities) offer potential for
flexibility and scope as outlined by Klasnja et al. (2012). Interoperability of health information systems continues to

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be fraught and difficult to resolve. Issues associated with privacy and ethics (Rivers, 2010, Craig et al., 2014) are
exacerbated for people with mental health issues.

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8. Appendices
1. DATA COLLECTED FROM ONLINE SURVEYS
Current top Australian e -mental health offerings: Awareness and Reach

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Current top Australian e-mental health offerings: Functionality

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Current top Australian e-mental health offerings: Overview

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2. RELEVANT DATA FROM RECENT LITERATURE
AUSTRALIAN eMH SERVICES and USAGE (Christensen et al., 2014)
SERVICE ORGANISATION
KEY AUDIENCE AND SERVICES PROVIDED
USAGE
HEALTH PROMOTION, WELLNESS PROMOTION AND PSYCHO-EDUCATION
Beacon
https://beacon.anu.edu.au/
• Key audience: consumers and health practitioners
• Provides guidance on the content, quality and availability of –
ehealth applications including online tools, mobile apps and online
support groups
• Consumer and researcher ratings are provided
• 9,810 unique visitors per month, on average.
• No registration required.
• 76,503 pages accessed per month, on average
Beyondblue
http://www.beyondblue.org.au/
• Key Audience: all Australians
• Communication and education through provision of
comprehensive information on depression and anxiety including
recognising symptoms
• Promotes early action and recovery
• 208,000 visitors per month, on average
• No registrations required
Black Dog Institute
http://www.blackdoginstitute.org.au
• Key audience: all Australians
• Information, education, psycho-education focused on depression,
bipolar disorder and anxiety disorders
• Screening tools, referrals to eMH programs and clinicians
• Contact point for community education programs
• 121,332 unique visitors per month, on average
• 276,115 unique page views per month, on average
• No registrations required
• 1,823,656 annual visitors
BluePages
http://bluepages.anu.edu.au
• Key audience: people with depression
• Evidence based information about depression
• Automated screening tools for depression and anxiety
• Information about the experience, symptoms and diagnosis of
depression
• Information about psychological, medical and alternative/lifestyle
treatments for depression
• 9,701 unique visitors per month, on average
• No registrations required
• 229,638 pages accessed per month, on average
HeadsUp
http://www.headsup.org.au/
• Key Audience: workplaces, employer groups and business
leaders
• Online resource providing information about mental health and the
workplace. The website offers simple tools e.g. an action plan for
business), practical advice, information and resources to take
action
• 87,000 visits to the website in first six weeks
• Since June launch 4,700 businesses and individuals have
registered for further information on mentally healthy
workplaces

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KidsMatter
National Primary Schools Mental
Health Initiative
www.KidsMatter.edu.au
• Key audience: school leadership, teachers and parents
• Objective: strengthen capacity of primary school communities to
support children’s social and emotional development and to
respond effectively to child mental health issues
• Provides online resources and training, links to evidenced-based
programs and services
• 2,000+ school communities currently participating
Man Therapy
www.mantherapy.org.au
• Key Audience: men - 30-54 years
• Practical information for men dealing with stress, anxiety and
depression
• Online screening tool and links to programs and services
• 691,302 website visits
• 152,000 completions of Man Quiz (K10)
• Has reached 41% of men aged 30 -54 years (approx 1.5
million)
•
mindhealthconnect
Healthdirect Australia
www.mindhealthconnect.org.au
• Key audience: National e-mental health website for the public and
health professionals
• Brings together Australia's leading mental health providers in one
place
• Find relevant mental health and wellbeing information, online
programmes, services, tools, news, helplines
• Operated by Healthdirect Australia, on behalf of the Australian
Federal Government
• Data not available at present
MindMatters
National Secondary Schools Mental
Health Initiative
• Key Audience: school leadership, teachers and parents
• Objective: strengthen capacity of secondary school communities
to support student resilience and to respond effectively to youth
mental health issues
• Provides online resources and training, links to evidenced-based
programs and services
• Online forums
• 1500 schools to be recruited through to mid-2016
ReachOut.com
www.reachout.com
• Key audience: young people aged 14-25
• Non-clinical mental health promotion and early intervention
service
• Information, self-help referral, peer support via online forum
• Anonymous, available 24/7, accessible on
computers/mobile/tablet
• Referral pathways (41% of distressed young visitors to the site
said they would be more likely to seek additional help after using
R/O)
• On average 170,000 unique visitors per month, on average
• No registration required
• 1.7 million annual visits on average

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PREVENTION AND EARLY INTERVENTION
beyondblue support service
24 hr – 1300 224636
• Key audience: people experiencing distress
• Telephone (24 hr – 1300 224636), email and web chat
counselling with trained mental health professional
• Provides brief interventions/support and referral
• 8,583 contacts per month, on average during the first full
year of operation – 2013/14 (telephone, email or web chat)
BiteBack
Black Dog Institute
http://www.biteback.org.au/
• Key audience: 12-18 year olds
• Prevention
• Services: well-being and resilience building
• 3,400 unique visits per month, on average
• 75 registrations per month, on average
• 2,646 registered users since 2011
Brave Online
https://brave4you.psy.uq.edu.au/
• Key audience: Children and adolescents with risk factors (e.g.
temperament) or early signs of anxiety
• Self-help, therapist assisted, or supported by school staff
• Full-automated
• Current pilot project with 2 schools, available to research
populations only
Climate Schools
www.climateschools.com.au
• Key audience: secondary school students
• Health education courses available via website, with teachers
delivering additional activities to reinforce online lessons: alcohol
education, alcohol and cannabis use, psychostimulant and
cannabis education
• 313 unique visitors per month, on average
• 3,716 page views per month, on average
• 90 schools currently registered and using the programme
e-couch
https://ecouch.anu.edu.au
• Key audience: adults aged 20-70years
• Information and automated self-help program that includes a
literacy component and online tools for prevention and treatment
of depression, generalised anxiety disorder and social phobia
• Two additional tailored streams for bereavement and loss, and
divorce and separation
• 1,000 community registrations per month, on average
• 7,256 unique visitors per month, on average
• 393,038 pages accessed per month, on average
eheadspace
www.eheadspace.org.au
• Key audience: 12-25year olds and their friends and families
• Early intervention
• Improving the availability and accessibility of free, confidential,
youth friendly clinical mental health support.
• Improving help seeking behaviours of young people and their
families.
• 1,526 unique registrations per month, on average
• 41,000 registrations since 2011
• For 54% of young people accessing eheadspace, this was
their first experience of seeking help.
Kids Helpline
1800 55 1800
www.kidshelp.com.au
• Key audience: children and young people aged between 5 and 25
years
• Kids Helpline Counselling Services – provides free, private and
confidential counselling and information/referral for children and
young people aged under 26 years across Australia via phone,
• 18,952 counselling contacts per month, on average (15,460
via phone; 1,978 via email; 1,514 via web)
• 44,531 unique visitors to Kids Helpline website per month, on
average
• 28,105 webpage views of Hot Topics covering information

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web and email
• www.kidshelp.com.au – provides a range of information and self-
help resources for children, young people and adult carers
and coping strategies for a variety of problems (14,526 page
views of “teens” Hot Topics; 10,666 page views of
“grownups” Hot Topics; 2,913 page views of “kids” Hot
Topics)
• 10,337 webpage views of self-submitted stories of young
people’s problems and their experiences contacting Kids
Helpline
• 480 connections with Search for a Service function, which
connects people with their local support services
• No registrations required
• More than 7.5 million contacts since the service started in
1991
MoodGYM
http://moodgym.anu.edu.au
• Key audience: people at risk of developing a common mental
health problem or who are experiencing depression or anxiety
symptoms
• Automated, self-help CBT for depression with 5 modules and 29
online exercises
• 9,400 community registrations per month, on average
• Over 800,000 registrations
• 36,834 unique visitors per month, on average
• 3,154,840 pages accessed per month, on average
New Access
http://www.beyondblue.org.au/resourc
es/health-professionals/newaccess-a-
beyondblue-program
• Key audience: people with mild-to-moderate depression / anxiety.
• Trained coaches provide individually tailored low intensity CBT to
clients incorporating e-mental health programs/supports
• Currently only available to research participants at three pilot
sires located in SA, ACT and NSW
CRISIS INTERVENTION AND SUICIDE PREVENTION
Lifeline
https://www.lifeline.org.au/
• Key audience: Australians experiencing a crisis
• Lifeline 13 11 14 – national telephone helpline
• Lifeline Online Crisis Support Chat Service – one on one
confidential chat service
• Lifeline Suicide Hot Spot crisis line – specialist telephone helpline
• Lifeline Online ‘Get Help – self-help resources at lifeline.org.au
• Lifeline 13 11 14: average 60,000+ calls per month, on
average
• Online Crisis Support Chat: average 2,500 contacts per
month
• Suicide Hot Spot Crisis Line: average 1,500 calls per month
• No registrations required
• lifeline.org.au – on average 58,000+ unique visitors per
month
• Online ‘Get Help’ resources – 8,000 unique page views per
month
• Referrals to other services – 2/3 of callers and chat visitors
receive referral to other services
iBobbly
Black Dog Institute
• Key audience: Aboriginal and Torres Strait Islander peoples aged
16-35 years.
• Treatment for suicidal ideation based on acceptance and
commitment therapy
• Currently undergoing upgrades and improvements
• Currently only available to research participants in pilot study
in the Kimberley, WA
• Public release date TBA
TREATMENT AND E-THERAPY SERVICES

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BraveOnline
http://www.brave.psy.uq.edu.au/index
_brave.html
• Key audience: children and adolescents with anxiety disorders
• Fully automated online intervention for anxiety in youth, delivered
via computer, mobile phone or tablet
• Minimal therapist assistance
• Cognitive behavioural therapy, problem solving therapy, cognitive
challenging, exposure
• delivered via 10 interactive modules for young people (plus
2booster sessions)
• 6 interactive modules for parents (plus booster sessions)
• Separate programmes for children vs adolescents
• Additional programme with specific sessions for social phobia
• To date, the clinician supported version of the programme is
only accessible via research group in Australia
• Being used with clinically anxious children post the
Christchurch earthquake
e-couch
http://ecouch.anu.edu.au
• Key audience: adults aged 20-70years
• Information and automated self-help program that includes a
literacy component and online tools for treatment of depression,
generalised anxiety disorder and social phobia
• Two additional tailored streams for bereavement and loss, and
divorce and separation
• 1,000 community registrations per month, on average
• 7,256 unique visitors per month, on average
• 393,038 pages accessed per month, on average
OnTrack, QUT
www.ontrack.org.au
• Key audience: Australians with a health problem
• Information services for a range of health conditions
• Self-rated quizzes on drinking, mood and relationships with
feedback supplied
• Interactive online programmes for depression, alcohol &
depression, family & friends, psychosis, flood and storm recovery,
diabetes
• iPhone/iPad apps for meditation
• iPad app, Stay Strong, which is used by workers in Indigenous
health settings
• 1,400+ unique visitors per month, on average
• No registrations required for screening
• 916 registrations for web programmes
• 63,526 page views since 2009
Mental Health Online
https://www.mentalhealthonline.org.a
u
• Key audience: adults aged 18 years or more
• Information and self-guided assessment for 21 disorders
• Guided and unguided self-help online CBT for generalised anxiety
disorder, obsessive compulsive disorder, panic disorder,
depression, insomnia, PTSD and social anxiety disorder, as well
as a trans-diagnostic programme (depression and anxiety) for
same-sex attracted young people
• Tailored integrated resources for people with comorbid problems
• Availability of therapist support via e-mail, text chat, voice-over
internet, video chat and within a VR space
• Additional programmes offered through participation in research
(e.g. depression, insomnia, compulsive hoarding)
• eTherapist Online training and placement opportunities
• 1,380 unique visitors per month, on average
• 625 registrations per month, on average
• 22,098 page views per month, on average
MoodGYM
http://moodgym.anu.edu.au
• Key audience: people with depression or anxiety symptoms.
Designed for young people but used by all ages.
• 9,400 community registrations per month, on average
• Over 800,000 registrations

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• Automated, self-help CBT for depression with 5 modules and 29
online exercises
• 36,834 unique visitors per month, on average
• 3,154,840 pages accessed per month, on average
myCompass
Black Dog Institute
www.mycompass.org.au
• Key audience: people with mild-mod depression and anxiety
• Fully automated online intervention for depression and anxiety,
delivered via computer, mobile phone or tablet
• Cognitive behavioural therapy, problem solving therapy, positive
psychology and interpersonal psychotherapy delivered via 12
interactive self-help modules
• Real time tracking/monitoring of symptoms
• 4,545 unique visits per month, on average (users and
general public)
• 310 registrations per month, on average
• 24,711 page view per month, on average
• 15,028 registered users since June 2012
SHADE
National Drug and Alcohol Research
Centre, UNSW
www.shadetreatment.com
• Key audience: people aged 18 years and over with depression
and comorbid substance use problems
• Fully automated online intervention incorporating CBT,
motivational enhancement training, mindfulness and relapse
prevention
• Minimal therapist assistance (10-15 minutes per session) via
email, telephone or in clinic
• Available in 10-session programme (weekly sessions) or a skills
module version (1-2 hours each)
• Clinician supported version of the programme is only offered
via research group in Australia
ThisWayUp
St Vincent’s Hospital
www.thiswayup.org.au
• Key audience: people with common mental health problems
• Online clinic for registered health providers and their patients
• CBT for major depressive disorder, generalized anxiety disorder,
panic disorder, social phobia, obsessive compulsive disorder, and
co-morbid anxiety and depression
• Self-help web intervention for mixed anxiety and depression, crisis
management, social phobia
• Online courses for schools to teach students how to manage
depression and anxiety, alcohol and drugs
• 1,000 unique visitors per month, on average
• Clinic site: 80 patient and 40 clinician registrations per month
on average
• 275 self-help site registrations per month, on average
• 6,000 registrations to self-help courses since
• 500 primary and high schools registered to use the courses
as part of their lessons
RECOVERY AND MUTUAL SUPPORT SERVICES
BlueBoard
http://blueboard.anu.edu.au
• Key audience: people with common mental health problems
• Moderated internet support group
• Available 24/7; moderated 7am-10pm
• Separate bulletin board forums for depression, bipolar, anxiety,
social anxiety, panic disorder and borderline personality disorder
• 110 new member registrations per month
• 6,073 posts per month, on average
• 5,408 unique visitors per month, on average
• 210,671 pages accessed per month, on average

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CLINICAL EFFECTIVENESS and COST EFFICIENCY of AUSTRALIAN eMH SERVICES (Christensen et al., 2014)
Name of programme
Number of
research trials
Effect sizes
Cost data
Setting
Target and
Reference
HEALTH PROMOTION, WELLNESS PROMOTION AND PSYCHO-EDUCATION SERVICES
BluePages
http://bluepages.anu.edu.au
1 x RCT (quasi
indicated
prevention)
Within group effect size: d=0.4 (depression
symptoms) and d=0.5 for completers
Between group effect size d=0.29 (depression
symptoms) and d=0.35 for completers (12m
follow up)
Community
Depression symptoms,
depression literacy;
reductions in stigma
(Mackinnon et al., 2008,
Griffiths et al., 2004)
PREVENTION, EARLY INTERVENTION AND SUICIDE PREVENTION
BiteBack
http://www.biteback.org.au/
1 x RCT
Between group effect sizes: overall d=0.22
(depression symptoms) d=0.34 (high
adherence users)
Open access,
Australia-wide,
community-based
trial
Well-being, resilience,
depression and anxiety
symptoms (Manicavasagar
et al., 2014)
Climate schools
www.climateschools.com.
au
3 x RCTs
Within group effect sizes at post: d=0.23
(average alcohol consumption), d=0.2 (binge
drinking).
AT 6 month follow up: d=0.18 (average alcohol
consumption); d=0.19 (cannabis use)
At 12 month follow-up: d= 0.38 (average
alcohol consumption), d=0.17 (binge drinking);
d=0.31 (cannabis use)
Australian
secondary school
students
Alcohol and drug use,
alcohol and drug knowledge,
alcohol and drug-related
harms, overall wellbeing.
(Newton et al., 2010)
eCouch
4 x RCT quasi-
indicated
University/staff users social anxiety stream e-
couch; Between group pre-post difference:
Community/young
people in the
Depression and anxiety
(Donker et al., 2013, Bowler
et al., 2012, Glozier et al.,

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http://ecouch.anu.edu.au
(see also: treatment data)
prevention trials +
1 x equivalence trial
d=0.71 – 0.93 (for social anxiety).
Spontaneous users; e-couch depression IPT
and CBT streams: Within group d= 0.80 (ITT)
and d=1.44 for completers (depression, CBT);
d= 0.67 (ITT) and d=1.02 (completers)
(depression, IPT)
Cardiovascular disease; d=0.18 (depression)
and d=0.16 (anxiety)
community
People with cardio
vascular disease
2013)
MoodGYM
https://moodgym.anu.edu.
au
8 x quasi-indicated
prevention; 1 x
universal
prevention
2 x RCT
Within group effect sizes: d=0.4 (depression)
and d=0.6 for completers
Unguided between group: g=1.19 (depression)
and g=0.23 (alcohol misuse) (6 mths)
Unguided between group: g= 0.57
(depression), g=0.74 completers and g=0.82
compliers
Between group effect size: MoodGYM vs
waitlist: d=0.23 (anxiety) d=0.27 (depression)
at 6 month follow up
Cost effective to translate
into another language: 16
QALYs gained per 1000
treated persons; CER=3432
Community
Schools
Universities
Lifeline
Workplace
NHS Choices
Brain injury
(Christensen et al., 2004,
Calear et al., 2013, Calear et
al., 2009)
CRISIS INTERVENTION AND SUICIDE PREVENTION
Lifeline
13 11 14
https://www.lifeline.org.au/
N/A
N/A
Social Return on Investment
study of Lifeline Online
Crisis Support Chat service
in 2013 calculated a return
of $8.40 for this service.
Community based
adults
Crisis intervention with
suicidal Australians
(netbalance, 2014)

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TREATMENT AND E-THERAPY SERVICES
BraveOnline
http://www.brave.psy.uq.e
du.au/index_brave.html
3 x RCTs
Within group effect sizes at 12 month follow up
d=1.85 (child self-reported anxiety); d=2.58
(Clinician Severity Rating)
Adolescents with
anxiety
Anxiety symptoms
(Spence et al., 2011,
Spence et al., 2006)
e-couch
https://ecouch.anu.edu.au
3 X RCTs +
1 equivalence trial
e-couch community users: Between group
effect size d=2.43 ( generalised anxiety)
University/staff social anxiety stream: Between
effect (social anxiety ‘cases’) OR=1.7 (social
anxiety)
Community users e-couch: Between effect
(depression ‘cases’): OR= 5.3 (depression)
Spontaneous users e-couch CBT: within group
effect sizes (depression ‘cases’) d= 0.65 (ITT,
6 mths; (depressive symptoms).
Community
(Metro/
regional/rural)
University
(Bowler et al., 2012, Donker
et al., 2013, Griffiths et al.,
2012)
Mental Health Online
https://www.mentalhealthonli
ne.org.au
Uncontrolled
ongoing ‘real world’
open access
service results
Within group effect sizes:
Social anxiety automated: d=0.84; Post
traumatic stress disorder automated : d=0.72;
Obsessive compulsive disorder automated:
d=0.83; Panic automated: d=1.12; Generalised
anxiety disorder automated : d=1.22;
In press data re: effect on depression:
Panic automated: d=.30; Post-traumatic stress
disorder automated: d=.36; Obsessive
compulsive disorder automated: d=.33;
Generalised anxiety disorder automated:
d=.42; Social anxiety disorder automated:
GAD Online:
Therapist-assisted vs face-
to-face 59% cost saving;
Self-help vs face-to-face
61% cost saving
Panic Online
iCBT $350 vs. telephone
CBT $378 vs. psycho-
education only $55
PTSD Online (V1)
PTSD ONLINE found to be
Open access real
world
Primary and secondary
mental health symptoms,
number of disorders,
confidence in managing
mental health and
psychological distress
(Klein et al., 2011, Klein et
al., 2010, Klein et al., 2006)

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d=.07
3.7 times less expensive
than the current cost for
psychological therapist time
in the traditional face-to-face
modality.
Anxiety Online (whole
service)
Estimated labour time cost
saving resulting from the
Anxiety Online service in the
first 18 months of operation
is therefore estimated at AU
$6.7 million.
MoodGYM
http://moodgym.anu.edu.au
8 x RCT+2CTs + 1
equivalence trial +1
uncontrolled trial
(one TBI)
Within group effect sizes: d=0.9 (depression
caseness) completers
Callers Lifeline; Between group effect 6 mths
(depression ‘cases’): 1.2 (ITT) and 1.4
completers
Spontaneous users: Within group effect
(depression ‘cases’): =0.61 and 1.36 for
completers (at 6 mths).
University students between group: g=0.68-
0.86 (mild to severe depression ‘cases’)
completers and g=0.40-0.90 compliers,
Guided primary care between group effect size
at post: d=0.65 & d=1.1
Spontaneous
users; schools;
universities;
primary care (GP
supported);
psychologists;
Lifeline; NHS
Choices online
health portal;
public mental
health services;
brain injury
Anxiety Depression
(Høifødt et al., 2013, Donker
et al., 2013, Farrer et al.,
2011)
myCompass
www.mycompass.org.au
1 x RCT
1 x uncontrolled
trial (diabetes
related distress)
Between group effect sizes at post:
myCompass vs attention control - d=0.36
(depression); d=0.4 (anxiety); d=0.22 (stress);
d= 0.22 (work and social adjustment)
myCompass vs waitlist d=0.46 (depression);
Net Monetary Benefits for
MyCompass are $12187 for
12 months vs $9245 for
face-to-face CBT and $9206
for TAU. [unpublished]
Adults with mild-
moderate
depression, stress
and anxiety
Anxiety, depression & work
and social adjustment
(Proudfoot et al., 2013b,
Harrison et al., 2011)

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d=0.47 (anxiety); d=0.35 (stress); d=0.29 (work
and social adjustment)
Within group effect sizes myCompass d=0.24
(anxiety)-0.49(depression, work and social
adjustment)
Diabetes trial within group effect sizes at post
(unpublished):
d=1.05 (depression); d=0.68 (anxiety); d=04
(work and social); d=1.15 (diabetes distress)
Diabetes within group effect sizes at 3 month
follow up: d=0.74 (depression); d=0.48
(anxiety); d=0.57 (work and social); d=1.04
(diabetes distress)
Adults with
diabetes related
distress and mild-
mod stress,
depression and
anxiety
OnTrack
www.ontrack.org.au
1 x RCT
1 x pilot
Between group effect sizes at 3 month follow
up:
Unguided brief vs full intervention: d=0.55
(depression); d=0.42 (psychological quality of
life)
Adults with
depression and
alcohol misuse
Depression and alcohol use
Depression and
psychological quality of life
QOL
SHADE
www.shadetreatment.com
2 x RCTs
3 x pilots
At 12-month follow-up: DEPRSSION: Clinician-
assisted SHADE (d=0.97) vs. therapist-
delivered CBT (d=1.16), vs. 1-session
(d=0.71), vs. supportive counselling (d=1.03);
ALCOHOL: Clinician-assisted SHADE (d=0.87)
vs. therapist-delivered CBT (d=1.05), vs. 1-
session (d=0.85), vs. supportive counselling
(d=0.75) CANNABIS: Clinician-assisted
SHADE (d=0.75) vs. therapist-delivered CBT
(d=0.53), vs. 1-session (d=0.07), vs.
supportive counselling (d=0.17).
SHADE used a minimum of
50% less clinician time than
the specialist therapist-
delivered CBT to produce
equivalent outcomes through
to 3-years post-treatment
Adults with
depression and
alcohol or
cannabis or
amphetamine use
in the community
.
Depressive symptoms
Alcohol use
Cannabis use
Amphetamine
(Kay-Lambkin et al., 2011,
Kay-Lambkin et al., 2009)
use

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94
THIS WAY UP
www.thiswayup.org.au
4 x RCT
CCCBT+Tel vs CCBT+Forum. Within group
effect sizes d=1.31-1.54
cCBT vs waitlist Within group d=0.98; between
group d=0.75
Worry vs waitlist: within group effect size d=1.3
and between group effect size d= 1.1
Social phobia: within group effect size d=0.86
(auto) and 1.15 (reminders)
THIS WAY UP Clinic
$1800/DALY averted;
This Way Up self-help
programme
$800/DALY averted
Community
volunteers with
social phobia,
depression,
anxiety
82 volunteers with
social phobia
45 diagnosed with
depression
48 diagnosed with
anxiety
163 with social
phobia
Shyness (Titov et al.,
2009b); depression(Perini et
al., 2009b);
anxiety ; social phobia
RECOVERY AND MUTUTAL SUPPORT SERVICES
BlueBoard
http://blueboard.anu.edu.au
1 x RCT
Unguided community users: BlueBoard
(adapted): Between group effect: Odds Ratio =
12.5. (12 mths]
Unpublished data – Within group effect size
for spontaneous BlueBoard users -
completers: d= 0.58 (depression)
Online support
group for people
with depression
Depression (Griffiths et al.,
2012, Griffiths et al., 2010a)

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95
Evidence-based e-Health Interventions for Mental Health Promotion
Table of References (Burns et al., 2014)
#
Reference
Mental
health
promotion
strategy
Study
type
Intervention
Study method
Findings
Summary of
evidence
1
Costin, D.L., Mackinnon A.J.,
Griffiths K.M., Batterham, P.J.,
Bennett A.J., Bennett, K., &
Christensen H. (2009). Health
e-cards as a means of
encouraging help seeking for
depression among young
adults: Randomized controlled
trial. Journal of Medical
Internet Research, 11, e42.
Promoting
Help Seeking
Attitudes &
Behaviours –
Psycho-
education
RCT
Depression e-cards:
Brief intervention
delivering
personalized emails
containing links to
depression information
to enhance help-
seeking outcomes.
348 young adults
randomised to basic or
enhanced depression
e-card intervention, or
attention-control.
Depression e-
cards associated
with significant
improvements in
help-seeking
intentions and
beliefs around
formal help
sources.
Depression e-
card delivery
associated with
significantly
improved
intentions and
attitudes towards
help-seeking.
2
Collin, P.J., Metcalf, A.T.,
Stephens-Reicher, J.C.,
Blanchard, M.E., Herrman,
H.E., Rahilly, K. & Burns, J.M.
(2011). ReachOut.com: The
role of an online service for
promoting help-seeking in
young people. Advances in
Mental Health, 10, 39-51.
Promoting
Help Seeking
Attitudes &
Behaviours –
Psycho-
education
Program
evaluation
- cross-
sectional
user
profiling
online
survey and
focus
groups
Reachout.com: A
website established
and maintained by the
Inspire Foundation
targeted at young
people aged 14- 25
years.
1,552 youth (14-25)
completed online
survey following visit
to ReachOut.com.
39% sought
information about
mental health
issues; on average
around half
reported
improvements in
skills, knowledge
and confidence in
help-seeking,
propensity to seek
help, and mental
health literacy;
A moderate
proportion of
young adult users
of ReachOut.com
found the site
useful and
facilitated help-
seeking
outcomes.

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!
96
35.2% reported
site assisted them
in asking for
professional help.
3
Shandley, K., Austin, D., Klein,
B., Kyrios, M. (2010). An
evaluation of ‘Reach Out
Central’: an online gaming
program for supporting the
mental health of young people.
Health Education Research,
25(4), 563-57
Promoting
Help Seeking
Attitudes &
Behaviours –
Psycho-
education
Quasi-
experiment
al repeated
measures
trial
Reach Out Central
(ROC): Online
educational game with
virtual interactive
scenarios designed to
support the mental
health of youth aged
16-25, based on CBT.
Single group of 266
youth aged 18-25
assessed at pre, post
and 2 month follow-up
after 4 weeks of play
on ROC.
Positive
improvements
over time were
found for females
in use of positive
coping strategies,
life satisfaction,
resilience, help-
seeking intentions
and reductions in
alcohol use and
avoidance
behaviours.
Conversely, for
males a non-
significant
worsening effect
was observed for
some outcomes.
Females
appeared to gain
greater benefits
from use of ROC
than males for a
range of mental
wellbeing and
behavioural
outcomes.
Further controlled
trials are
required, with
particular
attention paid to
enhancing
acceptability and
effectiveness for
both genders.
4
Christensen, H., Griffiths,
K.M., & Jorm, A.F. (2004).
Delivering interventions for
depression by using the
Internet: Randomised
controlled trial. British Medical
Journal, 328, 265-268.
Promoting
Help Seeking
Attitudes &
Behaviours –
Psycho-
education
RCT
BluePages: A website
that provides
information on
treatments for
depression, screening
tests, and links to
other evidence-based
resources.
525 individuals with
elevated depression
randomly
allocated to
depression information
website, MoodGYM
CBT training website
or attention-control.
Significant
increases in
participants’
understanding of
effective evidence-
based treatments
for depression.
Use of
BluePages
associated with
improved literacy
regarding
appropriate
depression
treatments.
5
Dunt, D., Robinson, J.,
Promoting
Internal
Beyondblue InfoLine:
Internal audit of calls
Infoline provided
Infoline is

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97
Selvarajah, S., Young, L.,
Highet, N., Shann, C. & Pirkis,
J. (2011) beyondblue,
Australia's national depression
initiative: An evaluation for the
period 2005 – 2010.
International Journal of Mental
Health Promotion, 13, 22-36,
Help Seeking
Attitudes &
Behaviours –
Psycho-
education
data
evaluation
(published
as a
report)
A 24-hour telephone
helpline that operates
seven days a week,
providing callers with
access to information
and referral to relevant
services where
necessary.
between July 2007 -
December
2008.
information,
referrals & help to
73,129 callers.
Calls increased
substantially since
its inception in
2006 (average
increase of 150
calls/month).
Callers included
consumers (45%),
third party e.g.,
relative (36%) and
professional
(15%).
44% of consumer
callers were male,
and over 25%
were from regional
or remote areas.
accessed by a
broad range of
individuals,
including
consumers and
their networks
across both
genders and rural
communities. The
service appears
to be extending
its reach, with a
steadily
increasing
number of callers
accessing the
service.
6
Finkelstein, J., & Lapshin, O.
(2007). Reducing depression
stigma using a web-based
program. International Journal
of Medical Informatics, 76,
726-734.
Enhancing
Community
Attitudes &
Stigma
Reduction -
Intensive
Educational
Interventions
Pre – post
trial
CO-ED: A web-based
depression stigma
program delivered to
healthcare professionals
which is effective for
reducing stigma
associated with
depression.
42 graduate
students and
university staff
completed
intervention; pre-
post assessment.
Significant
improvements in
depression literacy
and reduction in
depression stigma.
Web-based
education tool
was effective in
reducing
depression
stigma and
enhancing
knowledge
around

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98
depression.
7
Finklestein J., Lapshin O., &
Wasserman E. (2008).
Randomised study of different
anti-stigma media. Patient
Education and Counselling,
71, 204-14.
Enhancing
Community
Attitudes &
Stigma
Reduction -
Intensive
Educational
Interventions
RCT
CO-ED: A web-based
depression stigma
program delivered to
healthcare professionals
which is effective for
reducing stigma
associated with
depression.
193 graduate
students allocated
to 3 groups: anti-
stigma printed
materials; anti-
stigma computer
program, or no
intervention
(control); assessed
post-test and 6
months.
Computer-assisted
delivery of anti-
stigma educational
content decreased
stigmatising
attitudes and
increased
knowledge at post-
test and 6 month
follow up,
compared to the
reading group, and
to control.
Computer-
assisted
educational anti-
stigma materials
was effective in
reducing
psychiatric
stigma and
improving
knowledge of
mental illness at
post-test and 6
month follow-up.

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99
Evidence-based e-Health Interventions for Mental Illness Prevention
Table of References (Burns et al., 2014)
#
Reference
Mental health
promotion
strategy
Study type
Intervention
Study method
Findings
Summary of
evidence
8
Gardner, P. C., Moore, J. T.,
Cigularov, K. P., Putter, S.
E., Sampson, J. M.,
Maertens, J., Chen, P. Y.,
Quinnett, P., & Baker, A.
(2009, April). Comparison of
online and face-to-face
gatekeeper training. Paper
presented at the 42nd
American Association of
Suicidology Annual
Conference, San Francisco,
CA.
Prevention of
Suicide, Suicidal
Ideation and
Behaviour –
Gate keeper
training
Non-
randomised
pre-post
trial
QPR (Question,
Persuade, Refer): A
program designed to
train community
members who may
be in contact with
suicidal individuals to
identify those at risk
and assist with
referring to
appropriate mental
health services.
107 Australians
participated in the
web-based version
of QPR training and
853 Americans in
the face-to-face
QPR training.
Both groups
demonstrated gains
in knowledge post-
test and declines at
follow-up. Web-based
QPR group showed
more improvement in
self-efficacy at post-
test but this gain was
not maintained at
follow-up. Both
groups showed gains
in intentions to
engage in suicide
intervention post-test
but only the online
group maintained
these intentions at
follow up.
The results of this
study are
promising for the
utility of the web-
based QPR
training, however
they need to be
replicated in a
RCT. Further, it is
not clear how
these training
programs directly
impact actual
gatekeeper
behaviour or
suicidal
ideation/behaviou
r in those who
are at risk.
9
van Spijker, B.A., Majo, M.C.,
Smit, F., van Straten, A., &
Kerkhof, A.J. (2012).
Reducing suicidal
Prevention of
suicide, suicidal
ideation and
behaviour –
RCT &
cost-
effectivene
ss analysis
Living with Deadly
Thoughts: Online
self-help CBT
program to reduce
236 adults
experiencing mild-
moderate suicidal
ideation,
Significantly larger
proportion of
individuals who
received the
Online self-help
CBT program on
top of CAU
increases the

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100
ideation: Cost-
effectiveness analysis of a
randomized controlled trial of
unguided web-based self-
help. Journal of Medical
Internet Research, 14, 141.
Web Based
Programs For
Reducing
Suicidal Ideation
suicide ideation.
randomised to
intervention or
waitlist, information-
only control. All
participants
received care as
usual (CAU)
intervention
demonstrated
clinically significant
reductions in suicidal
ideation (35% vs.
21% in the control
group); with a saving
of, €34,727 (US
$41,325) societal
costs relative to CAU.
likelihood of
clinically
significant
reduction in
suicidal ideation,
at lower cost.
10*
Lifeline (2009). Crisis
Support through 13 11 14.
Lifeline: Deakin West, ACT
[available online
http://www.lifeline.org.au/Abo
ut-Lifeline/Research-and-
reports/Research-and-
Reports]
Prevention of
suicide, suicidal
ideation and
behaviour –
Crisis
Intervention
Internal
data
evaluation
(published
as a report)
Lifeline Crisis Telephone
Service: 13 11 14 is a
confidential telephone
crisis support service
available 24/7 from a
landline, payphone or
mobile.
Cross-sectional
analysis of Lifeline
call data sample
(2008-2009).
5.8% of calls
identified as
suicide related (45-
50 calls/day); 10%
of suicide-related
calls required
emergency service
attendance for
direct intervention;
32% of suicide-
related calls
reported mental
health and 33%
reported
‘aloneness and
support’ as a main
concern.
Lifeline provides
support to highly
vulnerable
population
groups with high
suicide risk,
receives suicide-
related calls and
facilitates
interventions
where
appropriate for
these suicide-
related calls to
ensure safety.
11
Christensen, H., Farrer, L.,
Batterham, P.J., Mackinnon,
A., Griffiths, K.M., & Donker,
T. (2013). The effect of a
web-based depression
Prevention of
suicide, suicidal
ideation and
behaviour –
Crisis
RCT
Lifeline Crisis Telephone
Service: Weekly 10
minute calls to previous
Lifeline callers were
made by Lifeline
155 Lifeline callers
with elevated
psychological
distress
randomised to
Regardless of
intervention,
participants
demonstrated
significant declines
Suicide ideation
declines over
time both with
and without
proactive

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101
intervention on suicide
ideation: Secondary outcome
from a randomised controlled
trial in a helpline. BMJ Open.
Intervention
counsellors.
NB: intervention
examined within an RCT
(compared to other
active interventions).
internet CBT
(MoodGYM) plus
weekly telephone
follow-up; internet
CBT only; weekly
telephone follow-
up only or wait-list
TAU control.
in suicidal ideation
over time (12
months).
Telephone call
back group
showed significant
reduction in
suicidal ideation
from pre to post-
intervention, 6 and
12 months follow-
up.
intervention.
Weekly call back
by Lifeline
counsellors was
equally as
effective as
alternative
interventions and
no intervention, in
the resolution of
suicidal ideation.
12*
Kids Helpline (2008).
Satisfaction & Efficacy
Report: Understanding Client
Satisfaction and the
Service’s Efficacy in
Increasing a Young Person’s
Ability to Cope. BoysTown:
Milton, QLD
[available online
http://www.kidshelp.com.au/g
rownups/news-
research/research-
reports/research.php]
Prevention of
suicide, suicidal
ideation and
behaviour –
Crisis
Intervention
Survey
Kids Helpline: A free, 24
hour counselling service
for young people aged 5-
25 years. Counselling is
offered by phone, email
and over the web.
Two telephone
surveys conducted
by Kids Helpline
counsellors with
77 young people
at the end of their
counselling
session.
95% clients were
found to be
“satisfied” or “Very
satisfied” with the
service. 96%
reported having
gained some idea
on how to manage
their problem.
92% reported
confidence in their
ability to manage.
Kids Helpline
appears to
increase a young
person’s ability
and confidence to
deal with their
issues, and the
service is in line
with the needs of
callers.
13
O'Kearney, R., Gibson,
M., Christensen, H., Griffiths,
K.M. (2006). Effects of a
cognitive-behavioural internet
program on depression,
vulnerability to depression
and stigma in adolescent
Indicated
prevention of
depression and
anxiety - School
based screening
& CBT
School-
based
controlled
trial
MoodGYM: Online self-
help CBT program
78 males aged 15-
16 allocated to
MoodGYM or
standard PE
education classes;
assessed post-test
Those completing
3+ MoodGYM
modules showed
small relative
benefits in
depressive
symptoms and
Tentative support
for reduction in
risk of depression
and small
improvements in
depression
symptoms and

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102
males: A school-based
controlled trial. Cognitive
Behaviour Therapy, 35, 43-
54.
and 16 weeks.
attributional style
and a small
reduction in risk of
becoming
depressed; all of
which approached
significance at
post-test. These
results were not
maintained at
follow-up.
attributions
following
moderate
exposure to
MoodGYM as an
indicated
program;
however, results
did not reach
significance.
Unable to
endorse
MoodGYM as an
effective
indicated
program for
depression in
school-aged
males.
14
O'Kearney, R., Kang, K.,
Gibson, M., Christensen,
H., & Griffiths, K.M. (2009). A
controlled trial of a school-
based Internet program for
reducing depressive
symptoms in adolescent
girls. Depression and
Anxiety, 26, 65-72.
Indicated
prevention of
depression and
anxiety - School
based screening
& CBT
School-
based
controlled
trial
MoodGYM: Online self-
help CBT program
157 females aged
15-16 allocated to
MoodGYM or
usual PE
curriculum.
Significantly faster
rate of decline in
self-reported
depressive
symptoms
observed in
MoodGYM group
compared to
controls at 20
week follow-up
(d=.46, 95% CI
.10-.82). No
Some benefits
demonstrated
from MoodGYM
on self-reported
depressive
symptoms only.

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103
significant
intervention effects
on depression
status or
attributional style.
15
Dietz, D.K., Cook, R.F.,
Billings, D.W., Hendrickson,
A. (2009). A web-based
mental health program:
reaching parents at work.
Journal of Pediatric
Psychology, 34, 488-494.
Indicated
prevention of
depression and
anxiety - Parent
training and
family
strengthening
RCT
Youth Mental Health: A
Parents’ Guide (YMH):
Online multimedia skills
and knowledge-
enhancement program
(Social Cognitive Theory-
based) for working
parents with
adolescents.
99 working parents
allocated to online
program or waitlist
control.
YMH yielded
improvements in
parents’ self-
efficacy and
knowledge around
childhood mental
illness and its
treatment.
Online
multimedia
program was
effective in
improving
parental
knowledge and
confidence in
addressing
childhood mental
illness.
16
Kenardy, J., McCafferty, K.,
& Rosa, V. (2003). Internet-
delivered indicated
prevention for anxiety
disorders: A randomised
controlled trial. Behavioral
and Cognitive
Psychotherapy, 31, 279–289
Indicated
Prevention of
Depression and
Anxiety -
General adults
CBT for
depression &/or
anxiety
RCT
Online Anxiety
Prevention Program:
Online anxiety
prevention CBT program.
83 university
students with
heightened anxiety
sensitivity
allocated to online
program or waitlist
control.
Significant
reductions in self-
reported
depression
symptoms and
anxiety-related
cognitions for
those receiving
online CBT relative
to control.
Online CBT is
effective in
reducing anxiety-
related cognitions
and depressive
symptoms
relative control.
17
Ellis, L., Campbell, A.J.,
Sethi, S., & O'Dea, B.M.
(2011). Comparative
Randomized Trial of an
Indicated
Prevention of
Depression and
RCT
MoodGYM: Online self-
help CBT program.
39 young adults
(18-25 years) with
elevated distress
allocated to
Relative to control,
MoodGYM
participants
demonstrated
Initial positive
benefits for
anxiety and CBT
literacy following

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104
online cognitive-behavioural
therapy program and an
online support group for
depression and anxiety.
Journal of Cyber Therapy &
Rehabilitation, 4, 461-467.
Anxiety -
General adults
CBT for
depression &/or
anxiety
MoodGYM (online
CBT), online
support group or
control.
improvements in
anxiety symptoms
and CBT literacy
at post-test.
use of
MoodGYM,
however long
term outcomes
require
examination.
18
Mackinnon, A., Griffiths,
K.M., &Christensen, H.
(2008). Comparative
randomised trial of online
cognitive–behavioural
therapy and an information
website for depression: 12-
month outcomes. British
Journal of Psychiatry, 192,
130-134.
Indicated
Prevention of
Depression and
Anxiety
General adults
CBT for
depression &/or
anxiety
RCT
MoodGYM: Online self-
help CBT program.
525 adults
allocated to online
CBT (MoodGYM)
or placebo control
(online depression
information
website).
Both online CBT
and depression
information
website associated
with significant
reductions in
depression
symptoms at post-
test, which were
maintained at 6
and 12 months in
the CBT condition
compared to
placebo control.
Some evidence
that benefits of
internet-delivered
CBT is effective
in reducing
depression
immediately and
over time.
19
Billings, D.W., Cook,
R.F., Hendrickson, A., Dove,
D.C. (2008). A web-
based approach to
managing stress
and mood disorders in
the workforce. Journal of
Occupational and
Environmental Medicine, 50,
Indicated
Prevention of
Depression and
Anxiety -
General adults
CBT for
depression &/or
anxiety
RCT
Stress and Mood
Management: Web-
based multimedia health
promotion program for
workers.
309 working adults
randomly assigned
to web-based
program or waitlist
control.
Significant
improvements in
help-seeking
attitudes,
knowledge of
depression and
anxiety, and
reduced stress
levels in the online
treatment group
Preliminary
suggestion of
positive effects in
stress
management,
help-seeking
attitudes and
knowledge of
mental illness.

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!
105
960-8.
relative to controls.
20
Harrison, V., Proudfoot, J.,
Wee, P.P., Parker, G.,
Pavlovic, D.H.,
Manicavasagar, V. (2011).
Mobile mental health: Review
of the emerging field and
proof of concept study.
Journal of Mental Health, 20,
509-24.
Indicated
Prevention of
Depression and
Anxiety -
General adults
CBT for
depression &/or
anxiety
Feasibility
proof of
concept
study; pre-
post
uncontrolle
d trial
My Compass: web and
mobile-based self-help
program for mild-
moderate stress, anxiety
and depression.
44 adults used
MyCompass for 6
weeks, with pre-
post assessment.
Significant
reductions in
general
psychological
distress, stress,
depression and
anxiety symptoms
at post-test,
compared to pre-
test scores,
following 6 weeks
using
MyCompass.
Significant
improvement in
symptoms of
stress,
depression,
anxiety and
distress following
use of
MyCompass.
21
Calear, A.L., Christensen, H.,
Mackinnon, A., Griffiths, K.M.
& O’Kearney, R. (2009). The
YouthMood Project: A cluster
randomized controlled trial of
an online cognitive
behavioral program with
adolescents. Journal of
Consulting and Clinical
Psychology, 77, 1021-1032
Universal
Prevention of
Depression and
Anxiety - High
School Based
CBT
Stratified,
cluster RCT
MoodGYM: An online,
self-directed cognitive–
behavioral therapy
program designed to
prevent or decrease the
symptoms of anxiety and
depression in
adolescents.
32 Australian
schools (N = 1,477
Year 9, 10 and 11
students) were
randomised to the
intervention
(MoodGYM) or a
waitlist control
condition.
At post-
intervention and 6-
month follow-up,
participants in the
intervention
condition had
lower levels of
anxiety than those
in the
control condition.
Only males in the
intervention
condition showed
reduced
depressive
Although small to
moderate, the
effects obtained
provide support
for the
utility of universal
online prevention
programs in
schools.

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106
symptoms at post-
intervention and 6-
month follow-up.
22
Calear, A.L., Christensen, H.,
Mackinnon, A. & Griffiths,
K.M. (2013). Adherence to
the MoodGYM program:
Outcomes and predictors for
an adolescent school-based
population. Journal of
Affective Disorders, 147,
338–344
Universal
Prevention of
Depression and
Anxiety - High
School Based
CBT
Stratified,
cluster RCT
MoodGYM: An online,
self-directed cognitive–
behavioral therapy
program designed to
prevent or decrease the
symptoms of anxiety and
depression in
adolescents.
32 Australian
schools (N = 1,477
Year 9, 10 and 11
students) were
randomised to the
intervention
(MoodGYM) or a
waitlist control
condition . Those
in the intervention
group were then
classified as low or
high adherers to
the MoodGYM
program.
High adherers
reported stronger
effects on anxiety
and depression at
post-intervention
and follow-up than
low adherers (vs.
control). Predictors
of adherence:
Being in Year 9,
living in a rural
location and
having higher pre-
intervention levels
of depressive
symptoms.
Preliminary
support for the
positive
relationship
between program
adherence and
outcomes in a
school
environment. The
identification of
significant
predictors of
adherence will
assist in
identifying the
type of user who
will engage most
with an online
prevention
program.
23
Heinecke, B.E., Paxton, S.J.,
McLean, S.A., & Wertheim,
E.H. (2007). Internet-
delivered targeted group
intervention for body
dissatisfaction and
disordered eating in
Prevention of
Eating Disorders
And Body Image
Problems -
Community-
Based
RCT
My Body, My Life:
Weekly, CBT- based
online group sessions
facilitated by a guided
self-help manual and
trained therapist, plus
online discussion board.
73 girls (12 – 18
years) who self-
identified as
having body image
or eating
problems.
Randomly
Clinically
significant
improvements in
body
dissatisfaction,
disordered eating,
Preliminary
support for an
online group
intervention for
non-clinical girls
with disordered
eating behaviours

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107
adolescent girls: A
randomized controlled trial.
Journal of Abnormal Child
Psychology, 35, 379-391.
Programs
assignment to
intervention (My
Body, My Life) or a
delayed treatment
control group.
and depression
observed at post-
intervention and
maintained at
follow-up. Internet
delivery was
enthusiastically
endorsed.
or body image.
24
Cox, C. M., Kenardy, J. A.,
Hendrikz, J. K. (2010). A
randomized controlled trial of
a web-based early
intervention for children and
their parents following
unintentional injury. Journal
of Pediatric Psychology,
35(6), 581-592.
Prevention of
PTSD -
Prevention of
Post-Event
Pathology From
Post-Event
Intervention For
Those Who
Demonstrate
Vulnerability
RCT
So You've Been in an
Accident: Psycho-
educational website for
children and
adolescents.
85 children (7-16)
who had been
hospitalized
overnight with an
accidental
injury (including
mild traumatic
brain injury).
Children & their
families randomly
assigned to
intervention (an
information booklet
and website) or
control group.
Children within the
intervention group
reported improved
anxiety, in
comparison to
worsening
symptoms in the
control group.
Children with
higher baseline
trauma scores
reported the
intervention to be
helpful.
The online
intervention
showed
promising results
in its ability to aid
child recovery.
• Evaluation conducted in non-academic context

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New and emerging technologies in mental health promotion, early intervention and treatment:
Table of References(Burns et al., 2014)
#
Reference
Mental health
promotion
strategy
Study type
Intervention
Study method
Findings
Summary of
evidence
1
Christensen, H. and I. Hickie
(2010). "Using e-health
applications to deliver new
mental health services." Med
J Aust 192: S53-S56.
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
N/A
E-health services: how
these services are
delivering new and
innovative mental health
approaches.
Review of recent
research
publications.
Despite ‘successful’
public awareness
campaigns, school-
based prevention
programs and
reforming of the
primary care-based
mental health
system, individuals
experiencing a
diagnosable mental
health condition are
too often not
receiving adequate
care.
The facilitation of
promotion, prevention
and early intervention
programs and access
to care can be
improved by the
investment and
sector-wide uptake of
e-health services.
2
Burns, J., T. Davenport, H.
Christensen, G. M.
Luscombe, J. A. Mendoza, A.
Bresnan, M. Blanchard and I.
Hickie (2013). Game on:
Exploring the impact of
technologies on young men’s
mental health and wellbeing
Findings from the first Young
and Well National Survey.
Australia, The Young and
Well Cooperative Research
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Survey.
Utilising online services
and mobile apps to benefit
the mental health and
wellbeing of young men.
700 young men
completed a CATI
survey over the
phone.
Almost 50% of
young men said
coping with stress
was their biggest
issue, but less than
one-in-four young
men would
recommend
professional
support, either face-
to-face or online.
Young men are not
engaging with current
mental health
promotion, prevention
and early intervention
programs, and are
therefor reaching
crisis point before
receiving care.
Current research
suggests that by
more greatly using

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109
Centre.
online approaches,
young men are more
likely to engage with
strategies to
understand and
improve their mental
health and wellbeing.
3
Christensen, H. and I. B.
Hickie (2010). "E-mental
health: a new era in delivery
of mental health services."
Med J Aust 192(11).
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
N/A
E-mental health: briefly
outlining successful
models of e-mental health
care in Australia.
Review of recent
publications.
E-mental health can
overcome
traditional barriers
to care
(geographical,
financial and
attitudal) and
provide accessible
treatment to end
users.
Australia is leading
the world in the
development of e-
mental health
strategies, which are
significantly
improving access to
care and treatment
outcomes.
4
beyondblue (2013).
beyondblue Information
Paper: Improved access - e-
mental health programs.
Melbourne, beyondblue.
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Feasibility
proof of
concept
study, review
of current
literature.
E-mental health: outlining
the position of beyondblue
in improving people’s
access to mental health
care via e-mental health
strategies.
Review of recent
publications.
Via the provision of
evidence-based E-
mental health
programs and
strategies, it has
the potential to
increase access to
mental health
information,
treatment and
support.
With key stakeholders
working
collaboratively
(federal and state
government, peak
not-for-profits,
academics, and the
broader mental health
sector), a
comprehensive e-
mental health system
can be implemented.
5
Blanchard, M., A. Metcalf, J.
Degney, H. Herrman and J.
Enhancing
Community
Service
evaluation -
The report “investigated
the role that information
Sixteen focus
groups were
ICT plays an
enormous part in
Young people who
experienced

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110
Burns (2008). "Rethinking the
Digital Divide: Findings from a
study of marginalised young
people's ICT use." Youth
Studies Australia 27(4): 35-
42.
Attitudes,
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
focus groups
communication
technologies (ICT),
specifically the internet,
may play in promoting
mental health among
young people at risk of, or
experiencing,
marginalisation.”
conducted with 96
young people at 12
locations in rural,
regional and
metropolitan
Victoria.
the everyday lives
of marginalised
young people, with
a greater ease of
access that
hypothesised by
researchers prior to
the commencement
of the research.
marginalisation were
not necessarily
limited in their ability
to access the internet
and ICT services.
6
Blanchard, M., H. Herrman,
M. Frere and J. Burns (2011).
Attitudes informing the use of
technologies by the youth
health workforce to improve
young people's wellbeing:
Understanding the nature of
the "digital disconnect".
National Youth Sector
Conference 2011.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Online
questionnai-
re,
organisatio-
nal audits
and
interviews.
Investigating the current
role technology plays in
enhancing a young
person’s mental health, in
conjunction with
understanding the youth
mental health sector
professional’s
understanding and uptake
of technological
strategies.
Online
questionnaire
(n=233),
organisational
audits of five
multidisciplinary
youth health
services and
interviews with
expert opinion
leaders (n=9)
More than half of
the questionnaire
participants
believed that
technology
interventions have
a role to play in the
improvement of
young people’s
mental health.
However, from a
professional
perspective, there
was limited uptake
and understanding
of the available
online and
technologically
driven interventions
and programs.
Professionals have a
poor awareness of
the online and
technology sphere
that their
clients/patients
engage in on a daily
basis.
7
Burns, J., C. Morey, A.
Lagalee, A. MacKenzie and
J. Nicholas (2007). "Reach
Enhancing
Community
Attitudes,
Evaluation of
service.
Reachout.com: A website
established and
maintained by the Inspire
Review of internal
statistics and
Reach Out!
provides a reliable,
cost-effective and
Reach Out!
recognises the
potential that the wide

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111
Out! Innovation in service
delivery." Medical Journal
Australia 187: S31-34.
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Foundation targeted at
young people aged 14- 25
years.
research.
accessible service
delivering
information and
early intervention
strategies to young
people. Reach Out!
Pro is a service
aimed specifically
at mental health
sector
professionals, as
how to integrate the
tools Reach Out!
provides in care
plans.
provision of e-mental
health information
and programs, for
both young people
and mental health
professionals alike.
8
Burns, J., M. Blanchard and
A. Metcalf (2010). Bridging
the Digital Divide in Australia:
The Potential Implications for
the Mental Health of Young
People Experiencing
Marginalisation. Handbook of
Research on Overcoming
Digital Divides: Constructing
an Equitable and Competitive
Informative Society. K.
Killinger. US, IGI Global.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Review of
recent
publications.
The impact
technologically driven and
online mental health and
wellbeing strategies on
marginalised young
people.
Review of recent
literature,
particularly the
Bridging the Digital
Divide project.
9
Sensis and AIMIA (2013).
Yellow Social Media Report:
What Australian people and
businesses are doing with
N/A
Survey.
N/A
Survey of 515
individual
consumers and
1959 businesses.
Over the past year,
the social media
usage of
Australian’s has
increased, with the
Australian’s are
enthusiastic users of
social media, with
indicated growth in
relation to both

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112
social media.
survey indicating
that 65% of internet
users have a social
media presence.
personal and
business use.
10
Burns, J. M., T. A. Davenport,
L. A. Durkin, G. M. Luscombe
and I. B. Hickie (2010). "The
internet as a setting for
mental health service
utilisation by young people."
Med J Aust 192(11 Suppl):
S22-26.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitudes and
Behaviours –
Psycho-
Education
Cross-
sectional
RCT, CATI
telephone
interview.
N/A
2000 young people
aged 12-25 years
completed the
survey.
Of those surveyed,
76.9% of young
people expressed
using the internet to
connect with other
young people.
Twenty percent of
those who
answered survey
had experienced a
mental health
problem in the last
five years, with
30.8% of those
young people
having used the
internet to search
for information.
The report suggest
“technology is
important in the
everyday lives of
young people, and
online mental health
services that
encompass
promotion and
prevention activities
should include a
variety of resources
that appeal to all
ages and both sexes,
such as “question and
answer” forums and
email.”
11
Department of Health and
Ageing (2012). E-mental
health Strategy for Australia.
D. o. H. a. Ageing. Canberra,
Australian Government.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
N/A
N/A
Review of recent
literature.
The Australian
Government, by
funding a number of
small, evidence-
based projects, is
striding forward with
an agenda to widely
integrate e-mental
health
With strength of
evidence-based e-
mental health
programs and
strategies in Australia
and a collaborative
sector-wide
approach, the
Australian
Government has a

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113
Mental Health
valuable opportunity
for the further
investment in and
expansion of these
services.
12
Farrer, L., A. Gulliver, J.
Chan, P. Batterham, J.
Reynolds, A. L. Calear, R.
Tait, K. Bennet and K.
Griffiths (2013). "Technology-
Based Interentions for Mental
Health in Tertiary Students:
Systematic Review." Journal
Of Medical Internet Research
15(5).
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature; PubMed,
PsycInfo, and
Cochrane Central
Register of
Controlled Trials
databases were
searched using
keywords, phrases,
and MeSH terms. A
total of 28 papers
were included.
Overall, over 50%
of the outcomes
examined in this
study report one
positive outcome in
relation to the
treatment of the
end-user.
This report finds that
additional research is
required to establish
the effectiveness of
online interventions in
a university setting.
13
Medibank Health Solutions
and Nous Group (2013). The
Case for Mental Health
Reform in Australia: a Review
of Expenditure and System
Design, Medibank Health
Solutions and Nous Group.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature and data;
the report “provides
the most
comprehensive
estimate to date of
expenditure” on
mental health in
Australia.
The total
expenditure on
mental health in
Australia has been
found to be grossly
underestimated,
with Australia
spending in excess
of $28.6 billion per
year (excluding
costs associated
with loss of
productivity).
The Australian mental
health system is
inefficiently designed,
translating to “sub-
optimal” treatment
outcomes and
reduced accessibility
to services.

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114
14
Blanchard, M. (2011).
Navigating the Digital
disconnect Understanding the
use of information
communication technologies
by the youth health workforce
to help improve young
people’s mental health and
wellbeing PhD.
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
PhD Thesis.
N/A
233 members of
the youth mental
health sector
completed an
online
questionnaire,
organizational
audits of five
multidisciplinary
youth and
community mental
health services and
in-depth interviews
with eight leaders in
the fields of
psychiatry,
psychology, e-
health,
epidemiology and
.sociology.
Results from the
conducted research
suggest that
technology can play
a large and positive
role in the youth
mental health
sphere, “when used
alone or as an
adjunct to face-to-
face intervention,
as appropriate.” To
ensure these
positive outcomes
come to fruition,
more investment in
sector employees,
infrastructure and
research is
required.
Young people have
chosen ICT as their
preferred form of
communication,
presenting this
technological sphere
as a space to
“through which
mental health can be
improved.”
15
Dowling, M. and D. Rickwood
(2013). "Online Counseling
and Therapy for Mental
Health Problems: A
Systematic Review of
Individual Synchronous
Interventions Using Chat."
Journal of Technology in
Human Services 31(1).
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature; A
systematic search
was conducted
using the following
EBSCO databases:
Academic Search
Complete, CINAHL
Plus, Psychology
and Behavioral
Sciences
Collection,
PsychArticles, and
To support the roll-
out e-mental health
interventions, these
strategies and
approaches must
be supported by
research evidence
– it is here where
investment is
lacking, and the
number of RCTs
and large studies is
The findings of this
study indicate that
more evidence-based
research is required
to justify the
expansion of online
mental health
services.

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115
Psych INFO.
lacking.
16
Kauer, S. D., C. Mangan and
L. Sanci (2013). Does online
mental health improve help-
seeking for young people? A
systematic review, University
of Melbourne.
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature; Using
PRISMA guidelines,
literature searches
were conducted in
PubMed, PsycInfo
and the Cochrane
library. A total of 18
studies were
included.
The report finds a
lack of studies that
examine the effect
of technology on
help seeking in
young people aged
14-25 years. The
report doesn’t strive
“to say that there is
no benefit in online
services, rather that
this field has yet to
be properly
evaluated.”
This report describes
the effectiveness of
online means on
help-seeking.
17
Johnson, D., C. Jones, L.
Scholes and M. Carras
Colder (2013). Videogames
and Wellbeing: A
Comprehensive Review.
Melbourne, Young and Well
Cooperative Research
Centre.
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
research.
The report found
videogames have
been shown to
positively influence
young people’s
emotional state,
self-esteem,
optimism, vitality,
resilience,
engagement,
relationships, sense
of competence,
self-acceptance
and social
connections and
functioning.
This report explores
the positive effects of
videogames on young
people’s mental
health and wellbeing,
as well as calling for
further research into
this relationship.

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116
18
Collin, P., K. Rahilly, I.
Richardson and A. Third
(2011). The Benefits of
Socials Networking Services.
Sydney, Cooperative
Research Centre for Young
People, Technology and
Wellbeing.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature.
The usage of social
networking services
by young people
can have a positive
impact “delivering
educational
outcomes;
facilitating
supportive
relationships;
identity formation;
and, promoting a
sense of belonging
and self-esteem.”
This report finds there
are many positive
links between the
mental health and
wellbeing of young
people and the usage
of social networking
services.
20
Campbell, A. and F. Robards
(2013). Using technologies
safely and effectively to
promote young people's
wellbeing: A Better Practice
Guide for Services.
Abbotsford, NSW Centre for
the Advancement of
Adolescent Health,
Westmead and Young and
Well Cooperative Research
Centre.
Enhancing
Community
Attitudes,
Promoting
Help Seeking
Attitude, Web
Based
Programs For
Improving
Mental Health
Review of
recent
literature.
N/A
Review of recent
literature.
After reviewing
samples of
“Australian and
international
literature to identify
successful models
for using
technology to
engage young
people in health
services, design
and delivery,” the
authors formulated
a set of guidelines
for the sector.
The implementation
of a framework to
ensure the safe,
inclusive and
innovative use of
technology in the
delivery of mental
health and wellbeing
services is vital.

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117
3. Notable interviewee quotes
United Sector:
“We have the components of a great mental health system but require greater clarity of role”
“Willingness in the industry and a lot of good will, people will work together – there may be one exception, but
even that seems to be more aligned”
“There is a mutual respect between the university on non-university sector”
“They need long-term funding”
“KPIs are critical for accountability”
“Duplication with too many portals can be confusing”
“Need to know that if we want top grade services we need an evidence base”
“Recognise that we have government support that meets needs”
“There must be a strong working relationship across the sector, information should be shared to create a
consolidated evidence-base”
Consumer Choice:
“Consumers need choice; a little like a shopping experience”
“Let 100 flowers bloom”
“What’s not working is how consumers can tell the difference between services”
Integration:
“Facilitated by some type of tech system that allows sharing of data”
“Lack of integration is a problem”
“Technology integration is a major tester because there can be huge complexity around It”
Leadership:
“We are light years ahead of the rest of the world”
“Innovation needs to keep propelling things forward”
“We are all moving in the right direction”
“We need a national strategy on how to do this shift”
“There needs to be thought put into capacity building and capacity retention”
“Implementation: We need to implement what we know, which is e-mental health in Schools and e-mental health
in NGOs”
“There are services that have the endurance and effectiveness”
“Prevention doesn’t fit into a medical model of service support”
“Need to be supported by a public health system”

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118
“If we are serious about e-mental health, it needs to be treated as a real service”
“Resources of the rats and mice of the sector being used in a more efficient way”
“e-mental health is not the answer for all people, we don’t only want an online service. Needs integration, co-
ordination and seamless support”
“A lot of it is ego driven, we’ve lost our perspective the focus needs to be on the end user because of three and
four year cycles we get distracted because we are worried about survival”
“Continuity of funding is important as is certainty of funding”
“Subject matter expertise needs to be going”
“Current funding models; short term, encourage silos. In order to be heard, people defend their space”
“Resource a team who can support collaboration”
“Seamless, coordinated care is critical”
“Decisions need to be made with the sector”
Data:
“More data is just Gold”
“Consumer instant feedback, tracking how define going over time, input data about what someone is saying –
tailor the experience and make it truly interactive and begin to approximate what might happen”
“Data can then be taken to a face-to-face practice then excludes the practitioner benefits (hard copy or given
access to data by integrated systems – they can then monitor what is happen.”
“Developers must undertake iterative quality assurance and improvement”
“Data should be interrogated and then used to improve the system”
“Data is critical and if an organisation is collecting data, it should ensure that outcomes are optimized”
“For the Government, data is important in relation to outcomes and efficiency”
“Data should be fed back into health systems, it should be a flag”
Random Comments
“Let’s not reinvent the wheel, government should support an ecosystem of care”
“There is noise in the sector, no clear signpost in the community other than Lifeline”
“It must be holistic in approach, not just about e-mental health”
“The major obstacle is resources, which are often spread too thin – a consolidated model allows you to meet
demand”
“MindHealthConnect has added no value”
“Three Obstacles:
" Cohesive view of what the ecosystem should look like
" Review as new and emerging tech avenues
" Chaotic funding rather than co-ordination”

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“Underinvestment in impact data over time”
“Integration of ONLINE + OFFLINE”
“Face-to-face slow to integrate into enhanced care”
“Lack of imagination from traditional services”
“Given the tools to find and track the help wanted”
“Everyone has a niche, a lot of stuff needs to be done”
“Costs of eHealth small relative to 4 services – should free up funds for innovation”
“Untapped potential of peer work”
“Great online initiatives – people don’t know about them”
“No ecosystem that brings it together. This is how consumers + families can work through the system”
4. Collective Impact Framework
The following framework is based on the Young and Well CRC’s interpretation of Collective Impact. This has been
proven effective in addressing some of the system wide complex challenges which impact on the mental health
and wellbeing of young people aged 12 to 25. Essential to success is the commitment of key partners from non-
profit, academic, government and corporate sectors to share a common agenda of improving the mental health
and wellbeing of young people through the use of technology. The five core elements of the Collective Impact
framework are outlined below.

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5. Medico-legal and ethical issues and access to health
professionals
Clinical scope of practice: Certification organisations, such as medical, nursing and psychological councils,
associations and professional societies, do not overtly endorse the use of online services (Manhal-Baugus, 2001,
MDA National). There appears to be a preference for face-to-face care delivery, with telehealth being an optional
back up or secondary service delivery mode. Protocols and guidelines for, e.g. social media use, are being
developed but have not yet matured (Wade et al., 2012) . The International Society for Mental Health Online
(ISMHO) provides guidelines for websites, telephone helplines and other forms of online service
(http://ismho.org/resources/standards-for-online-practice/) The Australian Psychological Society
(http://www.psychology.org.au/essentials/etherapy/#s2) has developed guidelines for online therapy delivery.
Guidelines require regular updating due to the rapid development of new technologies and new ways of delivering
mental health services (Mohr et al., 2013).
Clinicians are usually licensed to practice in a certain country or region. Websites and phone services are obliged
to define the boundaries of their services but it is not always clear to consumers if they are within an appropriate
boundary (Recupero and Rainey, 2005).
Confidentiality and privacy: Some people prefer to use online services because they can be anonymous
(Recupero and Rainey, 2005). While the anonymity may be preferable to the consumer, it may create challenges
with follow up, and risk management for people in crisis. Patient identification requires alternatives to visual
verification, especially if there is a preference for anonymity by using pseudonyms (Recupero and Rainey, 2005).
Increasingly the use of encryption and data storage on secure servers is becoming common practice for
organisations offering clinical support online. This reduces the risk of confidentiality breaches, e.g. criminal
Internet breach, if encryption is not used (Manhal-Baugus, 2001, MDA National). Online service providers also
have a responsibility for ensuring that consumers have a clear understanding of the limitations of the technology
itself, e.g. lack of non-verbal cues, lack of integration with their usual mental health record however this is
dependent on the service offering and may not be appropriate for online interventions that promote self managed
care (MDA National, Manhal-Baugus, 2001).
Building the therapeutic alliance: Many people access online services with a desire to remain anonymous.
While facilitating a soft entry point and self managed care, a potential risk, particularly if a person is very unwell, is
the lack of continuity of care, limitations in the development of a therapeutic alliance should the illness be chronic
and debilitating, attrition from the service with no ability to follow up, and high attrition rates for self-managed use
of online asynchronous therapies. In face-to-face clinical care a high touch, technology supported approach is
advised in the early stages of building the therapeutic relationship, i.e. in person therapy followed by online
therapy, but this is not always possible, and rarely practiced in self-managed websites or telephone helplines
(Manhal-Baugus, 2001, Day and Kerr, 2012). The complexity of mental illnesses means that the consumers
preference might be to use online resources across multiple services, however a challenge is redirecting or
supporting a person to seek face-to-face care when technologies may not be appropriate or sufficient to meet
their needs (Recupero and Rainey, 2005, Manhal-Baugus, 2001). Rapport is difficult to build without ‘high touch’
(Manhal-Baugus, 2001, Wade et al., 2012, MDA National) which is often not an option in telephone or self-
managed website therapy.
Informed consent: The therapeutic alliance should include informed consent about the use and/or
appropriateness of phone/website or other online therapy. This consent is usually implied or recorded
electronically, visually or in writing, as part of commencement of the interaction. However, when visual cues are
missing, there is the risk of misunderstanding or misinterpretation (Recupero and Rainey, 2005, Wade et al.,
2012).
Liability: Medico-legal liability requires the establishment of duty of care protocols and the provision of a
reasonable quality of care (Wade et al., 2012) or what is considered by peers to be competent care (modified
Bolam Principle) (MDA National). Lines of accountability can be blurred when multiple providers from the same
service are involved in care at a distance. Telehealth (and by extension, e-mental health) in Australia has not
been tested in the courts (Wade et al., 2012) therefore one could assume that case law does not yet exist to

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enable liability assessment of mental health services via websites or phone helplines. The recordings of the
interactions could be used in court – however it is not clear how recordings of in-person interactions and
phone/online interactions compare as evidence in court or how patient privilege can be used, e.g. deleted SMS
messages or emails.
Access to health professionals: Telehealth services such as helplines and care via websites appear to be
easier to access than in-person services for people who live in remote rural environments, assuming people have
access to broadband, telephones and the Internet. Many people with mental health issues appear to prefer the
anonymity and distance that are afforded by such services (Manhal-Baugus, 2001, Wade et al., 2012).
Regardless of environment (urban vs rural, in-person vs virtual), some people with mental health issues prefer the
immediacy of telephone services such as LifeLine when in crisis. In contrast, it is not obvious when specific health
professionals are not available online or by phone (Recupero and Rainey, 2005). This could present risk to the
consumer who may have unrealistic expectations about the availability of their clinician or therapist. While
technology-mediated services may make services more immediate and accessible, the availability of specific
individuals is not predictable or transparent.
6. Risks specific to Telehealth
Telehealth often creates health information in formats that have not traditionally been part of people’s records,
e.g. audio recordings, video, remote monitoring data. Early thinking suggests that it is important to ensure that
responsibilities for securing and managing the health information generated are clearly defined, and each party is
aware of its responsibilities and the others, e.g. agreements on who is responsible for maintaining the information
and the levels of access. American health lawyers, Friedberg & Quashie (2014), identify three categories of
privacy and security law issues that can create heightened challenges in the telehealth setting:
DATA MANAGEMENT
Key questions include:
• Should the data be maintained as part of the “medical record”?
• Does the law or other statutory obligations require the information to be recorded and what obligations are
there to provide people with access to their information and disclosure?
• How and where is it being maintained and secured? The issue is data encryption and storage
• What consititutes data? Audio and video recordings, remote monitoring data, app data, big data, small data
etc.?
• What data should be included as a component part of a medical record?
• What are the legal and statutory requiremets regarding medico, legal and ethical issues?
• When is data being stored, managed and encrypted?
SHARING DATA MANAGEMENT RESPONSIBILITIES WITH
OTHER PROVIDERS
Current legislation regarding e-mental services including the Privacy Act 1988 and Australian Privacy Principles
state that:
2.1 If an APP entity holds personal information, the entity must take such steps as are reasonable in the
circumstances to protect the information:
a) from misuse, interference and loss; and
b) from unauthorised access, modification or disclosure.

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2.2 If:
a) an APP entity holds personal information about an individual; and
b) the entity no longer needs the information for any purpose for which the information may be used or disclosed
by the entity under this Schedule; and
c) the information is not contained in a Commonwealth record; and
d) the entity is not required by or under an Australian law, or a court/tribunal order, to retain the information;
e) the entity must take such steps as are reasonable in the circumstances to destroy the information or to ensure
that the information is de-identified.
PRIVACY AND SECURITY RISKS DURING THE TELEHEALTH
ENCOUNTER
There are risks that an encounter could result in privacy or security law violation. To minimise risk there needs to
be:
• Reliable methods for verifying and identifying identities of the service user and practitioner
• Quality of data transfer that comprises quality of the therapeutic alliance
Telehealth encounters may also be vulnerable to third party interference, signal errors, or transmission
outages. These types of incidents can result in the loss of data, interrupted communications, or the alteration of
important clinical information.

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References
AUSTRALIAN GOVERNMENT 2013. Review of the Personally Controlled Electronic Health Record. In:
DEPARTMENT OF HEALTH.
ABS 2008. Australian Bureau of Statistics National Survey of Mental Health and Wellbeing: summary of results,
2007. Canberra: ABS.
ACMA 2013. Communications Report 2012-13. In: AUSTRALIAN COMMUNICATIONS AND MEDIA AUTHORITY
(ed.). Australian Government.
AHOLA, R., PYKY, R., JÄMSÄ, T., MÄNTYSAARI, M., KOSKIMÄKI, H., IKÄHEIMO, T. M. & KORPELAINEN, R.
2013. Gamified physical activation of young men--a Multidisciplinary Population-Based Randomized
Controlled Trial (MOPO study). BMC Public Health, 13, 32.
AISBETT, D., BOYD, C., FRANCIS, K. & NEWNHAM, K. 2007. Understanding barriers to mental health service
utilisation for adolescents in rural Australia. Rural and Remote Health, 7.
ALEXANDER, J. & LATTANZIO, A. 2009. Utility of telepsychiatry for Aboriginal Australians. Aust N Z J
Psychiatry, 43.
AUSTRALIAN COMMUNICATIONS AND MEDIA AUTHORITY 2009. Click and connect: Young Australians' use
of online social media.
AUSTRALIAN GOVERNMENT 2008. Quality Framework for Telephone Counselling and Internet-based Support
Services. In: DEPARTMENT OF HEALTH AND AGING (ed.).
AUSTRALIAN GOVERNMENT 2012. E-mental health strategy for Australia. In: DEPARTMENT OF HEALTH AND
AGING (ed.).
AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 2007. Young Australians: their health and wellbeing.
Canberra: Australian Institute of Health and Welfare.
BERGSTRÖM, J., ANDERSSON, G., LJÓTSSON, B., RÜCK, C., ANDRÉEWITCH, S., KARLSSON, A.,
CARLBRING, P., ANDERSSON, E. & LINDEFORS, N. 2010. Internet-versus group-administered
cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial. BMC
Psychiatry [Online], 10.
BLANCHARD, M. 2011. Navigating the Digital disconnect Understanding the use of information communication
technologies by the youth health workforce to help improve young people’s mental health and wellbeing.
Journal of Adolescent Health, 48, S83.
BLANCHARD, M., HERRMAN, H., FRERE, M. & BURNS, J. 2012. Attitudes informing the use of technologies by
the youth health workforce to improve young people's wellbeing: Understanding the nature of the "digital
disconnect". Youth Studies Australia, 31, S1: S14-24.
BLANCHARD, M., METCALF, A., DEGNEY, J., HERRMAN, H. & BURNS, J. 2008. Rethinking the Digital Divide:
Findings from a study of marginalised young people's ICT use. Youth Studies Australia, 27, 35-42.
BOWLER, J. O., MACKINTOSH, B., DUNN, B. D., MATHEWS, A., DALGLEISH, T. & HOPPITT, L. 2012. A
comparison of cognitive bias modification for interpretation and computerized cognitive behavior therapy:
effects on anxiety, depression, attentional control, and interpretive bias. J Consult Clin Psychol, 80,
1021-33.
BOYD, C., FRANCIS, K., AISBETT, D., NEWNHAM, K., SEWELL, J., DAWES, G. & NURSE, S. 2007. Australian
rural adolescents' experiences of accessing psychological help for a mental health problem. Aust J Rural
Health, 15, 196-200.
BROOKS, E., MANSON, S. M., BAIR, B., DAILEY, N. & SHORE, J. H. 2012. The diffusion of telehealth in rural
American Indian communities: a retrospective survey of key stakeholders. Telemed J E Health, 18.
BUNCHBALL 2013. Gamification 101: An Introduction to the Use of Game Dynamics to Influence Behavior 2010.

! !
!
!
!
124
BURNS, J., BLANCHARD, M. & METCALF, A. 2009. Bridging the digital divide in Australia: The potential
implications for the mental health of young people experiencing marginalisation. In: FERRO, E.,
DWIVEDI, Y., GIL-GARCIA, J. & WILLIAMS, M. (eds.) Overcoming digital divides: constructing an
equitable and competitive information society. Hershey: IGI Global.
BURNS, J., BLANCHARD, M. & METCALF, A. 2010a. Bridging the Digital Divide in Australia: The Potential
Implications for the Mental Health of Young People Experiencing Marginalisation. In: KILLINGER, K.
(ed.) Handbook of Research on Overcoming Digital Divides: Constructing an Equitable and Competitive
Informative Society. US: IGI Global.
BURNS, J., COLLIN, P., BLANCHARD, M., DE-FREITAS, N. & LLOYD, S. 2008. Preventing Youth
Disengagement and Promoting Engagement. Australian Research Alliance for Children and Youth.
Inspire Foundation and ORYGEN Youth Health Research Centre.
BURNS, J., DAVENPORT, T., CHRISTENSEN, H., LUSCOMBE, G., MENDOZA, J., BRESNAN, A.,
BLANCHARD, M. & HICKIE, I. 2013. Game on: Exploring the impact of technologies on young men’s
mental health and wellbeing Findings from the first Young and Well National Survey. Australia: Young
and Well Cooperative Research Centre.
BURNS, J., DAVENPORT, T., DURKIN, L., LUSCOMBE, G. & HICKIE, I. 2010b. The internet as a setting for
mental health service utilisation by young people. Medical Journal of Australia, 192, S22-6.
BURNS, J., HICKIE, I. & CHRISTENSEN, H. 2014. Strategies for adopting and strengthening e-mental health. A
review of the evidence. Australia: Awaiting publication in 2014 by SAX Institute.
BUSINESS COUNCIL OF AUSTRALIA 2011. Using Microeconomic Reform to Deliver Patient Centred
Healthcare. Port Jackson Partners Ltd.
BUTTERFLY FOUNDATION 2012. Paying the price: The economic and social impact of eating disorders in
Australia. Melbourne: Butterfly Foundation for Eating Disorders compiled by Deloitte Access Economics.
CALEAR, A. & CHRISTENSEN, H. 2010. Review of internet-based prevention and treatment programs for anxiety
and depression in children and adolescents. Medical Journal of Australia, 192, S12-14.
CALEAR, A. L., CHRISTENSEN, H., MACKINNON, A. & GRIFFITHS, K. M. 2013. Adherence to the MoodGYM
program: Outcomes and predictors for an adolescent school-based population. J Affect Disorders, 147,
338-344.
CALEAR, A. L., CHRISTENSEN, H., MACKINNON, A., GRIFFITHS, K. M. & O’KEARNEY, R. 2009. The
YouthMood Project: A cluster randomized controlled trial of an online cognitive behavioral program with
adolescents. J Consult Clin Psych, 77, 1021-1032.
CHIPPS, J., BRYSIEWICA, P. & MARS, M. 2012. Effectiveness and feasibility of telepsychiatry in resource
constrained environments - systematic review of the evidence. Afr J Psychiatry, 15.
CHRISTENSEN, H., GRIFFITHS, K. & EVANS, K. 2002. e-Mental Health in Australia: Implications of the Internet
and Related Technologies for Policy. Canberra: Commonwealth Department of Health and Ageing.
CHRISTENSEN, H., GRIFFITHS, K. M. & JORM, A. F. 2004. Delivering interventions for depression by using the
internet: randomised controlled trial. BMJ, 328, 265.
CHRISTENSEN, H. & HICKIE, I. 2010a. Using e-health applications to deliver new mental health services. Med J
Aust, 192, S53-S56.
CHRISTENSEN, H. & HICKIE, I. B. 2010b. E-mental health: a new era in delivery of mental health services. Med
J Aust, 192, S2-3.
CHRISTENSEN, H., MURRAY, K., CALEAR, A. L., BENNETT, K., BENNETT, A. & GRIFFITHS, K. 2010a.
Beacon: a web portal to high-quality mental health website for use by health professonals and the public.
Med J Aust, 192, S40-S44.
CHRISTENSEN, H. & PETRIE, K. 2013. State of the e-mental health field in Australia: Where are we now?
Australian and New Zealand Journal of Psychiatry, 47, 117-120.

! !
!
!
!
125
CHRISTENSEN, H., PROUDFOOT, J., WOODWARD, A., KLEIN, B., MORGAN, C., KAVANAGH, D., ANDREWS,
G., HARMAN, G., J, B., BLANCHARD, M., ZACHAN, J., GRIFFITHS, K., STROUD, K., TEESSON, M.,
KAY-LAMBKIN, F., THOMAS, N., SCHARR, S. & HUMPHREYS, T. 2014. e-Mental Health in Australia
2014: Current and Future.
CHRISTENSEN, H., PROUDFOOT, J. G., ANDREWS, G., KLEIN, B., KAVANAGH, D., O'NEIL, D.,
WOODWARD, A., YOUNG, L. & GRAHAM, K. 2010b. E-mental health: a 2020 vision & strategy for
Australia.
CISCO. 2013. Cisco visual networking index: global mobile data traffic forecast update, 2013–2018 [Online].
Available: http://www.cisco.com/c/en/us/solutions/collateral/service-provider/visual-networking-index-
vni/white_paper_c11-520862.html [Accessed September 2014 2014].
COAG 2006. National action plan on mental health 2006-2011. In: COUNCIL OF AUSTRALIAN GOVERNMENTS
(ed.). Canberra.
COHEN, I. 2013. Consumer Mobile Health Impact Assessment: How the Use of Mobile Impacts Disease
Treatment and Therapy. Digitas Health.
COLLIN, P. & BURNS, J. 2008. The Experience of Youth in the Digital Age. In: FURLONG, A. (ed.) Handbook of
Youth & Young Adulthood: New Perspectives. Oxford: Routledge.
COLLIN, P., RAHILLY, K., RICHARDSON, I. & THIRD, A. 2011. The Benefits of Socials Networking Services.
Sydney: Cooperative Research Centre for Young People, Technology and Wellbeing.
CRAIG, L., SPRIGGS, M., ARNOLD, M. & PEARCE, C. 2014. Unresolved Ethical Challenges for the Australian
Personally Controlled Electronic Health Record (PCEHR) System: Key Informant Interview Findings.
AJOB Empirical Bioethics, 5, 30 - 36.
CUIJPERS, P., VAN STRATEN, A. & ANDERSSON, G. 2008. Internet-administered cognitive behavior therapy
for health problems: a systematic review. J Behav Med, 31, 169-77.
DAY, K. & GU, Y. 2012. Influencing factors for adopting Personal Health Records (PHRs). In: MAEDER, A. J. &
MARTIN-SANCHEZ, F. J. (eds.) Health Informatics: Building a Healthcare Future Through Trusted
Information - Selected Papers from the 20th Australian National Health Informatics Conference. Studies
in Health Technology and Informatics. Sydney: IOS Press.
DAY, K. & KERR, P. 2012. The potential of telehealth 'business as usual' in outpatient clinics. Journal of
Telemedicine & Telecare, 18, 1357-633.
DEGNEY, J., HOPKINS, B., HOSIE, A., LIM, S., VERMA, A. & VOGL, G. 2012. Counting the Cost: The impact of
young men's mental health on the Australian economy. Sydney: Inspire Foundation and Ernst & Young.
DETERDING, S., DIXON, D., KHALED, R., & NACKE, L. E. 2011. From Game Design Elements to Gamefulness:
Defining “Gamification.” Tampere, Finland: MindTrek’11.
DONKER, T., BENNETT, K., BENNETT, A., MACKINNON, A., VAN STRATEN, A., CUIJPERS, P.,
CHRISTENSEN, H. & GRIFFITHS, M. K. 2013. Internet-delivered interpersonal psychotherapy versus
internet-delivered cognitive behavioral therapy for adults with depressive symptoms: randomized
controlled noninferiority trial. J Med Internet Res, 15, e82.
DONKER T, P. K., PROUDFOOT J, CLARKE J, BIRCH M-R, CHRISTENSEN H 2013. Smartphones for smarter
delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15.
DRUSS, B. G. & DIMITROPOULOS, L. 2013. Advancing the adoption, integration and testing of technological
advancements within existing care systems. General Hospital Psychiatry, 35, 345-348.
FARRER, L., CHRISTENSEN, H., GRIFFITHS, K. M. & MACKINNON, A. 2011. Internet-based CBT for
depression with and without telephone tracking in a national helpline: randomised controlled trial. PLoS
ONE, 6, e28099.

! !
!
!
!
126
FARRER, L., GULLIVER, A., CHAN, J., BATTERHAM, P., REYNOLDS, J., CALEAR, A. L., TAIT, R., BENNET, K.
& GRIFFITHS, K. 2013. Technology-Based Interentions for Mental Health in Tertiary Students:
Systematic Review. Journal Of Medical Internet Research, 15.
FIORDELLI, M., DIVIANI, N., & SCHULZ, P. J. 2013. Mapping mHealth research: A decade of evolution. Journal
of Internet Medical Research, 15.
GARTNER RESEARCH 2011. Innovation Insight: Gamification Adds Fun and Innovation to Inspire Engagement.
GERRITS, R., VAN DER ZANDEN, A., VISSCHER, R. & CONIJIN, B. 2007. Master your mood online: A
preventive chat group intervention for adolescents. Australian e-Journal for the Advancement of Mental
Health, 6.
GLOBAL OBSERVATORY FOR EHEALTH SERIES 2011. mHealth: New horizons for health through mobile
technologies. World Health Organisation.
GLOZIER, N., CHRISTENSEN, H., NAISMITH, S., COCKAYNE, N., DONKIN, L., NEAL, B., MACKINNON, A. &
HICKIE, I. 2013. Internet-delivered cognitive behavioural therapy for adults with mild to moderate
depression and high cardiovascular disease risks: a randomised attention-controlled trial. PLoS One, 8,
e59139.
GLYNN, S., RANDOLPH, E., GARRICK, T. & LUI, A. 2010. A proof of concept trial of an online psychoeducational
program for relatives of both veterans and civilians living with schizophrenia. Psychiatric Rehabilitation
Journal, 33, 278-287.
GORDON, M. E. 2013. The history of app pricing, and why most apps are free [Online]. Flurry Analytics.
Available: http://www.flurry.com/bid/99013/The-History-of-App-Pricing-And-Why-Most-Apps-Are-Free -
.VCuHoimSyxQ.
GORMAN, D., BROUGH, M. & RAMIREZ, E. 2003. How young people from culturally and linguistically diverse
backgrounds experience mental health: some insights from mental health nurses. International Journal
of Mental Health Nursing, 12.
GOULD, M. S., MUNFAKH, J. L. H., LUBELL, K., KLEINMAN, M. & PARKER, S. 2002. Seeking help from the
internet during adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 41,
1182-1189.
GREENHALGH, T., HINDER, S., STRAMER, K., BRATAN, T. & RUSSELL, J. 2010. Adoption, non-adoption, and
abandonment of a personal electronic health record: case study of HealthSpace. Bmj, 341.
GRIFFITHS, K. 2013. A virtual mental health community – A future scenario. Australian & New Zealand Journal of
Psychiatry, 47, 109-110.
GRIFFITHS, K., CRISP, D., CHRISTENSEN, H., MACKINNON, A. & BENNETT, K. 2010a. The ANU WellBeing
study: a protocol for a quasi-factorial randomised controlled trial of the effectiveness of an Internet
support group and an automated Internet intervention for depression. BMC Psychiatry, 10, 20.
GRIFFITHS, K., FARRER, L. & CHRISTENSEN, H. 2010b. The efficacy of internet interventions for depression
and anxiety disorders: a review of randomised controlled trials. Med J Aust, 192, S4-11.
GRIFFITHS, K. M., CHRISTENSEN, H., JORM, A. F., EVANS, K. & GROVES, C. 2004. Effect of web-based
depression literacy and cognitive-behavioural therapy interventions on stigmatising attitudes to
depression: randomised controlled trial. Br J Psychiatry, 185, 342-9.
GRIFFITHS, K. M., FARRER, L. & CHRISTENSEN, H. 2010c. The efficacy of internet interventions for depression
and anxiety disorders: a review of randomised controlled trials. Medical Journal of Australia, 192, S4-11.
GRIFFITHS, K. M., MACKINNON, A. J., CRISP, D. A., CHRISTENSEN, H., BENNETT, K. & FARRER, L. 2012.
The effectiveness of an online support group for members of the community with depression: a
randomised controlled trial. PLoS ONE, 7, e53244.
GROS, D. F., STRACHAN, M. & RUGGIERO, K. 2011. Innovative service delivery for secondary prevention of
PTSD in at-risk OIF-OEF service men and women. Contemp Clinical Trials, 32.

! !
!
!
!
127
HAAS, A., KOESTNER, B., ROSENBERG, J., MOORE, D., GARLOW, S., J, SEDWAY, J., NICHOLAS, L.,
HENDIN, H., MANN, J. & NEMEROFF, C., B 2008. An Interactive Web-Based Method of Outreach to
College Students at Risk of Suicide. Journal of American College Health, 57, 15-22.
HAMPSHIRE, A. & DI NICOLA, K. 2011. What's worrying young Australians and where do they go for advice and
support? Policy and practice implications for their well‐being. Early Intervention in Psychiatry, 5, 12-16.
HAPPTIQUE. 2012. Happtique App Certification Program [Online]. Happtique. Available:
http://www.happtique.com/wp-content/uploads/App-Certification-Standards-final.pdf 2013].
HARRISON, V., PROUDFOOT, J., WEE, P. P., PARKER, G., PAVLOVIC, D. H. & MANICAVASAGAR, V. 2011.
Mobile mental health: Review of the emerging field and proof of concept study. J Ment Health, 20, 509-
524.
HEDMAN, E., LJOTSSON, B. & LINDEFORS, N. 2012. Cognitive behavior therapy via the Internet: a systematic
review of applications, clinical efficacy and cost-effectiveness. Expert Rev Pharmacoecon Outcomes
Res, 12, 745-64.
HEDMAN, E., LJOTSSON, B., RUCK, C., BERGSTROM, J., ANDERSSON, G., KALDO, V., JANSSON, L.,
ANDERSSON, E., ANDERSSON, E., BLOM, K., EL ALAOUI, S., FALK, L., IVARSSON, J., NASRI, B.,
RYDH, S. & LINDEFORS, N. 2013. Effectiveness of internet-based cognitive behaviour therapy for panic
disorder in routine psychiatric care. Acta Psychiatr Scand, 128, 457-67.
HICKIE, I., DAVENPORT, T., SCOTT, E., HADZI-PAVLOVIC, D., NAISMITH, S. & KOSCHERA, A. 2001. Unmet
need for recognition of common mental disorders in Australian general practice. Medical Journal of
Australia, 175, S18-24.
HICKIE, I. B., DAVENPORT, T. A., LUSCOMBE, G. M., MOORE, M., GRIFFITHS, K. M. & CHRISTENSEN, H.
2010. Practitioner-supported delivery of internet-based cognitive behaviour therapy: evaluation of the
feasibility of conducting a cluster randomised trial. MJA, 192.
HIDES, L., KAVANAGH, D., STOYANOV, S., ZELENKO, O., TJONDRONEGORO, D. & MANI, M. To be
published 2014. Mobile Application Rating Scale (MARS). A new tool for assessing the quality of health
mobile applications. Melbourne: Young and Well Cooperative Research Centre.
HIDES, P. L. 2014. Are SMART apps the future of youth mental health.
http://www.psychology.org.au/Content.aspx?ID=5850 [Online]. [Accessed September 2014].
HILTY, D. M., FERRER, D. C., BURKE, M., JOHNSTONE, B., DALLAHAN, E. J. & YELLOWLEES, P. M. 2013.
The effectiveness of telemental helath: A 2013 review. Telemed e-Health, 19.
HØIFØDT, S. R., LILLEVOLL, R. K., GRIFFITHS, M. K., WILSGAARD, T., EISEMANN, M., WATERLOO, K. &
KOLSTRUP, N. 2013. The clinical effectiveness of web-based cognitive behavioral therapy with face-to-
face therapist support for depressed primary care patients: randomized controlled trial. J Med Internet
Res, 15, e153.
HORRIGAN, J. 2009. Wireless internet use, Pew Internet & American Life Project Washington, DC.
HUNTER, E., TRAVERS, H., GIBSON, J. & CAMPION, J. 2007. Bridging the triple divide: performance and
innovative multimedia in the service of behavioural health change in remote Indigenous settings.
Australasian Psychiatry, S15, S44-48.
INFORMIT. 2014. The Fight for The Mobile App Market: Android vs. iOS. Available from:
http://www.informit.com/blogs/blog.aspx?uk=The-Fight-for-The-Mobile-App-Market-Android-vs-iOS
[Accessed September 2014].
KAELBAR, D. C., JHA, A. K., JOHNSTON, D., MIDDLETON, B. & BATES, D. W. 2008. A research agenda for
personal health records (PHRs). Journal of the American Medical Informatics Association, 15, 729 - 736.
KALTENTHALER, E., SHACKLEY, P., STEVENS, K., BEVERLEY, C., PARRY, G. & CHILCOTT, J. 2002. A
systematic review and economic evaluation of computerised cognitive behaviour therapy for depression
and anxiety. Health Technol Assess, 6, 1-89.
KAUER, S. D., MANGAN, C. & SANCI, L. 2013. Does online mental health improve help-seeking for young
people? A systematic review. University of Melbourne.

! !
!
!
!
128
KAY-LAMBKIN, F. J., BAKER, A. L., KELLY, B. & LEWIN, T. J. 2011. Clinician-assisted computerised versus
therapist-delivered treatment for depressive and addictive disorders: results of a randomised controlled
trial. . Med J Aust, 195, S44-S50.
KAY-LAMBKIN, F. J., BAKER, A. L., LEWIN, T. J. & CARR, V. J. 2009. Computer-based psychological treatment
for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of
clinical efficacy. Addiction, 104, 378-88.
KENDLER, P. C. & KESSLER, R. C. 2002. The impact of childhood psychopathology interventions on subsequent
substance abuse: policy implications, comments, and recommendations. Journal of Consulting and
Clinical Psychology, 70, 1303-1306.
KLASNJA, P. & PRATT, W. 2012. Healthcare in the pocket: Mapping the space of mobile-phone health
interventions. . Journal of Biomedical Informatics, 45, 184 - 198.
KLEIN, B., MEYER, D., AUSTIN, D. W. & KYRIOS, M. 2011. Anxiety online: a virtual clinic: preliminary outcomes
following completion of five fully automated treatment programs for anxiety disorders and symptoms. J
Med Internet Res, 13, e89.
KLEIN, B., MITCHELL, J., ABBOTT, J., SHANDLEY, K., AUSTIN, D., GILSON, K., KIROPOULOS, L.,
CANNARD, G. & REDMAN, T. 2010. A therapist-assisted cognitive behavior therapy internet intervention
for posttraumatic stress disorder: pre-, post- and 3-month follow-up results from an open trial. J Anxiety
Disord, 24, 635-44.
KLEIN, B., RICHARDS, J. C. & AUSTIN, D. W. 2006. Efficacy of internet therapy for panic disorder. J Behav Ther
Exp Psychiatry, 37, 213-38.
LAL, S., ADAIR. C.E 2014. E-Mental Health: A Rapid Review of the Literature. Psychiatric Services, 65.
LENHART, A. & FOX, S. 2006. Bloggers: A portrait of the internet's new storytellers.
http://www.pewinternet.org/pdfs/PIP Bloggers Report July 19 2006.pdf: Pew Internet & American Life Project.
LIVINGSTONE, S. & HELSPER, E. 2007. Gradations in digital inclusion: children, young people and the digital
divide. New Media &amp; Society, 9, 671-696.
LOKKERBOL, J., ADEMA, D., CUIJPERS, P., REYNOLDS, C., SCHULZ, R., WEEHUIZEN, R. & SMIT, F. 2014.
Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing
telemedicine: a health economic modeling study. Am J Geriatr Psychiatry, 22, 253-62.
MACKINNON, A., GRIFFITHS, K. M. & CHRISTENSEN, H. 2008. Comparative randomised trial of online
cognitive-behavioural therapy and an information website for depression: 12-month outcomes. Br J
Psychiatry, 192, 130-4.
MANHAL-BAUGUS, M. 2001. E-therapy: practical, ethical, and legal issues. Cyberpsychol Behav, 4, 551-63.
MANICAVASAGAR, V., HORSWOOD, D., BURCKHARDT, R., LUM, A., HADZI-PAVLOVIC, D. & PARKER, G.
2014. Feasibility and effectiveness of a web-based positive psychology program for youth mental health:
Randomized controlled trial. J Med Internet Res, 16, e140 10.2196/jmir.3176.
MCGUIRE, A. L., FISHER, R., CUSENZA, P., HUDSON, K., ROTHSTEIN, M. A., MCGRAW, D., MATTESON, S.,
GLASER, J. & HENLEY, D. E. 2008. Confidentiality, privacy, and security of genetic and genomic test
information in electronic health records: points to consider. Genetics in Medicine, 10, 495-499.
MDA NATIONAL. Risk Management for Telemedicine Providers [Online]. Available:
http://www.mdanational.com.au/media/144805/telemedicine_providers.pdf [Accessed 10/9/2014.
MEDIBANK HEALTH SOLUTIONS & BEYOND BLUE 2013. Australia's Mental Health System - can we achieve
generational change?
MEDIBANK HEALTH SOLUTIONS & NOUS GROUP 2013. The Case for Mental Health Reform in Australia: a
Review of Expenditure and System Design. Medibank Health Solutions and Nous Group.
MENTAL HEALTH COMMISSION OF CANADA 2014. E-Mental Health in Canada: Transforming the Mental
Health System Using Technology. Ottawa.

! !
!
!
!
129
MENTAL HEALTH NETWORK, N. C. 2013. E-Mental Health, What's all the fuss about? Discussion Paper.
MITCHELL, J., VELLA-BRODRICK, D. & KLEIN, B. 2010. Positive psychology and the internet: A mental health
opportunity. Journal of Applied Psychology, 6, 30-41.
MOHR, D. C., CHEUNG, K., SCHUELLER, S. M., BROWN, C. H. & DUAN, N. 2013. Continuous evaluation of
evolving behavioral intervention technologies. American Journal of Preventive Medicine, 45, 517-523.
NATIONAL E-HEALTH TRANSITION AUTHORITY 2008. NEHTA Glossary.
NAZI, K. M. 2013. The Personal Health Record Paradox: Health Care PRofessionals' Perspectives and the
Information Ecology of Personal Health Record Systems in Organizational and Clinical Settings. journal
of Medical Internet Research, 15, e70.
NETBALANCE. 2014. Social Return on Investment Forecast of the Lifeline Online Crisis Support Chat Service
[Online]. Available:
https://http://www.lifeline.org.au/.../Lifeline_Online_Crisis_Support_Chat_SROI_report_final.pdf
[Accessed 11 Sep 2014.
NEWTON, N. C., TEESSON, M., VOGL, L. E. & ANDREWS, G. 2010. Internet-based prevention for alcohol and
cannabis use: final results of the Climate Schools course. Addiction, 105, 749-59.
NICHOLSON, S. 2012. A User-Centered Theoretical Framework for Meaningful Gamification. Proceedings of the
Games+Learning+Society 8.0 Conference, 223-230.
NIELSON 2013. The Mobile Consumer: A Global Snapshot.
NOTLEY, T. & FOTH, M. 2008. Extending Australia's Digital Divide policy: an examination of the value of social
inclusion and social capital policy frameworks. Institute for Creative Industries and
InnovationQueensland University of Technology.
ODOR, A., YELLOWLEES, P. M., HILTY, D. M., PARIS, M. B., NAFIZ, N. & LOSIF, A.-M. 2011. A system of
asynchronous telepsychiatry. Telemed e-Health, 17.
PERINI, D., TITOV, N. & ANDREWS, G. 2009a. Clinician-assisted Internet-based treatment is effective for
depression: Randomised controlled trial. Aust N Z J Psychiatry, 43, 571-578.
PERINI, S., ANDREWS, G. & TITOV, N. 2009b. Clinician-assisted Internet-based treatment is effective for
depression: Randomized controlled trial. Aust NZ J Psychiat, 43, 571-578.
PIRKIS, J., HARRIS, M., HALL, W. & FTANOU, M. 2011. Evaluation of the Better Access to Psychiatrists,
Psychologists and General Practitioners through the Medicare Benefits Schedule Initiative. University of
Melbourne: Centre for Health Policy, Programs and Economics.
PORTIO 2013. Mobile Applications Futures 2013-17: Analysis and Growth Forecasts for the Worldwide Mobile
Applications Market.
PROUDFOOT, J. 2013. The future is in our hands: The role of mobile phones in the prevention and management
of mental disorders. Australian & New Zealand Journal of Psychiatry, 47, 111-113.
PROUDFOOT, J., CLARKE, J., BIRCH, M.-R., WHITTON, A., PARKER, G., MANICAVASAGAR, V., HARRISON,
V., CHIRSTENSEN, H. & HADZI-PAVLOVIC, D. 2013a. Impact of a mobile phone and web program on
symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a
randomised control trial. BMC Psychiatry, 13.
PROUDFOOT, J., CLARKE, J., BIRCH, M. R., WHITTON, A. E., PARKER, G., MANICAVASAGAR, V.,
HARRISON, V., CHRISTENSEN, H. & HADZI-PAVLOVIC, D. 2013b. Impact of a mobile phone and web
program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and
stress: a randomised controlled trial. BMC Psychiatry, 13, 312.
RAO, V. 2013. Designing gamification for behavior change in mental health: challenges and perspectives
[Online]. Available:

! !
!
!
!
130
http://www.academia.edu/5184379/Designing_Gamification_for_Behavior_Change_in_Mental_Health_C
hallenges_and_Perspectives_E-Virtuoses_2013.
RECUPERO, P. R. & RAINEY, S. E. 2005. Forensic aspects of e-therapy. Journal of Psychiatric Practice, 11, 405
- 410.
RICE, T., ROSENAU, P., UNRUH, L. Y., BARNES, A. J., SALTMAN, R. B. & VAN GINNEKEN, E. 2013. Health
Systems in Transition. Health, 15.
RIVERS, A. 2010. eHealth Initiatives and Mental Health. Health Voices, 13.
ROSENBERG, S., HICKIE, I. B. & MENDOZA, J. 2009. National mental health reform: less talk, more action.
MJA, 190, 193-195.
ROTONDI, A., ANDERSON, C, HAAS, G, EACK, S, SPRING, M, GANGULI, R, NEWHILL, C, ROSENSTOCK, J
2010. Web-based psychoeducational intervention for persons with schizophrenia and their supporters:
one-year outcomes. Psychiatric Services, 61, 1099-1105.
RUBY, A., MARKO-HOLGUIN, M., FOGEL, J. & VAN VOORHEES, B. W. 2013. Economic analysis of an internet-
based depression prevention intervention. J Ment Health Policy Econ, 16, 121-30.
SENSIS & AIMIA 2013. Yellow Social Media Report: What Australian people and businesses are doing with social
media.
SPENCE, S. H., DONOVAN, C. L., MARCH, S., GAMBLE, A., ANDERSON, R. E., PROSSER, S. & KENARDY, J.
2011. A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. J Consult
Clin Psychol, 79, 629-42.
SPENCE, S. H., HOLMES, J. M., MARCH, S. & LIPP, O. V. 2006. The feasibility and outcome of clinic plus
internet delivery of cognitive-behavior therapy for childhood anxiety. J Consult Clin Psychol, 74, 614-21.
STRACHAN, M., GROS, D., KJ, R., CW, L. & ACIERNO, R. 2012. An integrated approach to delivering exposure-
based treatments for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings.
Behav Ther., 43.
SWAN, M. 2012. Health 2050: the realization of personalized medicine through crowdsourcing, the Quantified
Self, and the participatory biocitizen. Journal of Personalized Medicine, 2, 93-118.
TAIT, R. J. & CHRISTENSEN, H. 2010. Internet-based interventions for young people with problematic substance
abuse: a systematic review. MJA, 192, S15-S21.
THOMAS, S., HEINRICH, S., KUHNLEIN, A. & RADON, K. 2010. The association between socioeconomic status
and exposure to mobile telecommunication networks in children and adolescents. Bioelectromagnetics,
31, 20-7.
TITOV, N., ANDREWS, G., ROBINSON, E., SCHWENCKE, G., JOHNSTON, L., SOLLEY, K. & CHOI, I. 2009a.
Clincian-assisted Internet-based treatment is effective for generalised anxiety disorder: randomised
controlled trial. Aust N Z J Psychiatry, 43, 905-912.
TITOV, N., ANDREWS, G., SCHWENCKE, G., SOLLEY, K., JOHNSTON, L. & ROBINSON, E. 2009b. An RCT
comparing effect of two types of support on severity of symptoms for people completing internet-based
cognitive behaviour therapy for social phobia. Aust NZ J Psychiat, 43, 920-926.
TSAI, J. & ROSENHECK, R. A. 2012. Use of the internet and an online personal health record system by US
veterans: comparison of Veterans Affairs mental health service users and other veterans nationally.
Journal of the American Medical Informatics Association.
VAN DER KRIEKE, L., WUNDERINK, L., EMERENCIA, A.C., DE JONGE, P., SYTEMA, S. 2014. E-Mental Health
Self-Managment for Psychotic Disorders: State of the Art and Future Perspectives. Psychiatric Services,
65, 33-49.
VAN DER ZANDEN, R., KRAMER, J., GERRITS, R. & CUIJPERS, P. 2012. Effectiveness of an online group
course for depression in adolescents and young adults: A randomized trial. Journal of Medical Internet
Research, 14.

! !
!
!
!
131
VAN DER ZANDEN, R., SPEETJENS, P., ARNTZ, K. & ONRUST, S. 2010. Online group course for parents with
mental illness: Development and pilot study. Journal of Medical Internet Research [Online], 12.
VAN STRATEN, A., SEEKLES, W., VAN'T VEER-TAZELAAR, N. J., BEEKMAN, A. T. F. & CUIJPERS, P. 2010.
Stepped care for depression in primary care: what should be offered and how? 192, S36-S39.
VERASONI WORLDWIDE 2012. Mobile Health Applications: 2012 Study.
WADE, V., ELIOTT, J. A. & HILLER, J. E. 2012. A qualitative study of ethical, medico-legal and clinical
governance matters in Australian telehealth services. Journal of Telemedicine & Telecare, 18, 109 - 114.
WALLACE, D. & RAYNER, S. G. 2013. Telepsychiatry services in the Australian Defense Force. Australas
Psychiatry Bull R Aust New Zeal Coll Psychiatry, 21.
WEEK, I. 2013. Mobile Health Market to Reach $26B [Online]. Available:
http://www.informationweek.com/mobile/mobile-health-market-to-reach-$26b-by-2017/d/d-id/1110964?
[Accessed September 2014].
WHO. 2012. National eHealth Strategy Toolkit [Online]. Available: http://www.itu.int/pub/D-STR-E_HEALTH.05-
2012 [Accessed 14 August 2012].
WORLD HEALTH ORGANIZATION 2005. Promoting Mental Health. France: World Health Organization,
Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion
Foundation (VicHealth), University of Melbourne.
WORLD HEALTH ORGANIZATION 2011. mHealth. Global Observatory for eHealth 3.