Enhancing self-management for service users and carers: How can technology help?

Technology provides opportunities for change

Although structured psychological therapy is recommended by the National Institute for Clinical Excellence for a wide range of mental health conditions, in practice most people do not have ready access to these interventions. Although there have been a number of initiatives to improve access to psychological support, for example, Increasing Access to Psychological Therapies (IAPT) in the UK, Better Outcomes in Mental Health Care (BOiMHC) in Australia and “collaborative care” in the USA, difficulties persist. Self-management approaches have the potential to provide help to people who are not currently accessing formal care systems and to supplement care as routinely offered. Indeed, self-management informed by cognitive behavioural therapy (CBT) principles is an internationally recommended intervention for a range of mental health conditions, including mild to moderate depression (National Institute for Clinical Excellence [NICE], 2009; RANZCP, 2004b), mild obsessive compulsive disorder (OCD) (APA, 2007; NICE, 2005) and panic/agoraphobia (APA, 2009; RANZCP, 2003). Written plans that promote self-management are also encouraged in the treatment of bipolar disorder (NICE, 2006; RANZCP, 2004a). This issue of the Journal of Mental Health contains six papers all relevant to different aspects of self-management in mental health ranging from a consumer perspective on a diverse range of self-help techniques to consideration of the benefits of new technologies in the delivery and support of self-management interventions.

Self-help from a consumer perspective

The Journal of Mental Health is one of the few journals to include service users on its editorial board and to encourage service users as authors of papers (Gallop, 2010; Price et al., 2009; Rose et al., 2008). In the first paper of this special edition on self-management, Mayes (2011) provides an insightful personal account of the benefits and limitations of self-help materials from her perspective as a service user and researcher with a diagnosis of bipolar disorder. Mayes (2011) explores her own experiences with self-help books, creative pursuits, exercise, meditation, getting involved in service improvement and peer coaching with other service users. Overall, Mayes (2011) recommends self-help as an adjunct to professional support, particularly for longer term mental health problems. She concludes that while self-help promotes personal responsibility and is recovery focused, it is difficult for consumers to evaluate which self-help products are genuinely effective and which are claimed to be without real evidence. In line with these concerns, a recent review of 97 self-help books for depression found that most had not been rigorously evaluated and that almost half had a required reading age of over 15 years, substantially higher than the UK national average reading age of 9–10 years old (Richardson et al., 2008). Furthermore, the popularity of the books was not associated with either evidence-based contents or usability.

What works for affective disorders?

In paper 2, Ridgway and Williams (2011) review the research evaluating CBT self-help for depression and conclude that there is equivalent effectiveness compared with therapist-delivered therapy. The authors argue that traditional high-intensity models of care are insufficiently available to provide the necessary care to consumers as recommended by NICE guidelines. They therefore propose that stepped care models for depression are required in which low-intensity (LI) approaches constitute the first step. They conclude that initial findings for LI approaches in self-help provide evidence of effectiveness but require further evaluation.

In paper 3, Jones et al. (2011) trace the history of formalized self-management programmes, from initial studies of chronic disease management to UK Department of Health initiatives around the expert patient programme. The authors describe service user initiatives in the development of self-management programmes for mental health and review the existing literature on self-management efficacy for mood and anxiety disorders. The authors provide evidence for the suitability of self-management for bipolar disorder in particular and recommend more robust clinical trials to substantiate the findings of the few evaluative studies in this area.

What do people want?

In paper 4, Lobban et al. (2011) provide an account of the self-management preferences of 23 relatives of people with psychosis. With the aim of developing a Relatives Education and Coping Toolkit, the authors used focus group methodology to obtain family member input regarding content, format, potential barriers and benefits of a self-management toolkit. The resulting paper and web-based toolkit includes modules detailing symptom and treatment information, legal and financial issues, and strategies to manage carer stress levels. This toolkit, intended to supplement rather than replace specialist and crisis support from professionals, is currently being evaluated in a randomised controlled trial (RCT).

The importance of including stakeholders in research of this type is echoed by the work of Lucock et al. (2007), who reported on the views of service users regarding self-help research in the UK. The authors recommended the inclusion of stakeholders in self-help research in order to guide future studies and develop self-help strategies that will be perceived as useful and relevant to the recipient (Lucock et al., 2007).

Towards technology

In paper 5, Lovell and Bee (2011) review new treatments for OCD, including computerised CBT, telephone-delivered CBT and video conferencing. The authors conclude that preliminary research in this area has substantial methodological limitations, including lack of control groups, low power and only a minority of RCTs. Bearing these caveats in mind, Lovell and Bee (2011) reported high levels of participant satisfaction in these studies and some evidence of symptom improvements for participants with higher levels of engagement and motivation. Thus, technology-enhanced CBT for OCD warrants further attention in the form of large RCTs with adjunctive qualitative analysis to explore participant acceptability of novel forms of treatment (Lovell & Bee, 2011).

In paper 6, Harrison et al. (2011) describe an interactive mobile phone self-help program called “myCompass”. Twenty-eight participants with mild to moderate stress, anxiety and depression completed the 6-week myCompass program, which included CBT-based modules and short message service (SMS) prompts for regular and “real-time” self-assessments. Although small and uncontrolled, the evidence from this study for reductions in anxiety, stress and depression symptoms after the intervention, as well as improvements in general functioning and perceived self-efficacy is encouraging. Qualitatively, participants identified accessibility, convenience and interactive components of the program as positive.

Where to from here?

From the origins of various, unregulated self-help materials to online psychoeducation packages (Barnes et al., 2011) and the immediacy of informed and personalised mobile phone self-management programs (Harrison et al., 2011), self-management has developed the potential to provide person centred and evidence-based care to a larger number of individuals than primary health care can provide. Much more research is required, including qualitative analyses with service users to develop user-friendly, engaging and accessible self-management programmes, and rigorous RCTs to determine the effectiveness of such programs for specific disorders at different stages, including consideration of service user age and technology experience. What is clear, however, is that the increasing interest in self-management programmes in the research literature has ignited a novel, creative and contemporary approach to support individuals with mental illness in today's society.