E-mental health – a land of unlimited possibilities

Introduction

Around the globe, mental health research strategy documents highlight the need for urgent action to improve the state of mental health care (Insel, 2009; MRC, 2010). The need for improved dissemination of knowledge and specialist expertise and implementation of innovation, evidence-based interventions and services has been highlighted as a key aspect of ensuring improved care. In this context, it has been pointed out that “web-based mental health services have the capacity to not only overcome traditional geographical, attitudinal and financial barriers to access to care, but also to lower overall delivery costs and reduce demands on the clinical workforce” (Christensen & Hickie, 2010).

The general term e-health was coined in the 1990s to denote “healthcare practice supported by electronic processes and communication” (Wikipedia EHealth 2012). It also includes m-health, defined in a recent review (Free et al., 2010) as “the use of mobile computing and communication technologies in health care and public health”, for example, through personal digital assistants or smart phones. Finally, e-mental health has been described as

the use of information and communication technology (ICT) – in particular the many technologies related to the Internet – when these technologies are used to support and improve mental health conditions and mental health care, including care for people with substance use and comorbid disorders. E-mental health encompasses the use of digital technologies and new media for the delivery of screening, health promotion, prevention, early intervention, treatment or relapse prevention as well as for improvement of health care delivery (e.g., electronic patient files), professional education (e-learning), and online research in the field of mental health. (Riper et al., 2010)

E- and m-mental health are a rapidly expanding area of research and practice, although the expansion has not been as great as in other areas. For instance, Ennis et al. (2011) report that many papers on the use of electronic health records are mainly about medical conditions and that the word “mental” only occurs once in the vast majority of papers – in the exclusion criteria. So despite massive growth in this area there is still much to be studied if we are to harness electronic data for use in mental health services. In service of the need for some rapid gains there have been several previous themed journal issues which have covered the topic of e-mental health [e.g. Journal of Medical Internet Research, 19 December 2010, 12(5); Medical Journal of Australia, June 7 2010, 192(11 Suppl.)] showing that this is thought of as a vital area of potential for improvements in treatment delivery, shared care and decision making.

Much research in the area of e-mental health has focused on interactive online interventions, largely based on cognitive-behavioural approaches, for the treatment and prevention of common mental disorders such as depression and anxiety disorders (Griffiths et al., 2010), substance misuse disorders (Tait & Christensen, 2010) and some forms of eating disorders (Sánchez-Ortiz et al., 2011a; Schmidt et al., 2008), assessing questions of adherence (Donkin et al., 2011), efficacy, level and type of support needed, cost-effectiveness and how to integrate these interventions into stepped care approaches. Less is known about the experience of service users of these interventions, but studies assessing this are also beginning to emerge (Sánchez-Ortiz et al., 2011b). The treatment of common mental disorders is of course an area where even before the advent of e-mental health, evidence-based self-management interventions (usually delivered through self-help books), were well developed and widely available (Anderson et al., 2005; Lewis et al., 2003). There has been much less of a focus on the development and use of e-mental health interventions for severe mental disorders, however, e-mental health interventions for carers of people with severe mental disorders are beginning to emerge (Grover et al., 2011).

This special issue on e-mental health in the Journal of Mental Health adds to the growing literature in this area. Given the rapid growth of research and practice and speed of technological development in this area all we can do is provide a snapshot of some of the issues, covering diverse areas such as: questions of access to technology for people with severe mental illness, using the internet to develop a better understanding of the needs/intervening early with underserved/hard-to-reach populations (e.g. students with social anxiety, recreational drug users, eating disorder sufferers), novel developments in technology-assisted outcome monitoring, personalised feedback and real time therapy, and finally the exciting area of therapeutic gaming.

Access to technology, use of ICT to understand the needs of and intervene early in hard-to-reach or underserved communities

Most people in the UK, as in other developed countries, now have access to the internet. A key question for researchers and practitioners interested in the delivery of e-mental health is what access to ICT people with severe mental illness have who often have high levels of disadvantage and disability, and what their views are about its use. A survey of service users of community mental health services with severe mental disorders (Ennis & Wykes, 2012, this issue) showed that ICT access and use in this population is very similar to that of the general population. This is good news as it paves the way for the development of online-applications for this group of service users. Of note though, Black, Minority and Ethnic participants in the study were more likely to access computers outside of their own homes than white individuals. This brings with it the difficulty of how to ensure that these service users have sufficient privacy when engaging with web-content relevant to their mental health difficulties.

Russell and Topham (2012, this issue) conducted an online survey of University students, exploring the impact of social anxiety symptoms on their well-being and academic performance. A mixture of Likert scale questions and free text questions were used, allowing both quantitative and qualitative analysis. The survey identified a high proportion of students who experienced inhibition and discomfort in social settings. The free text comments paid moving testimony to the crippling nature of social anxiety and these students' sense of being alone with this difficulty and lack of availability of appropriate help. It highlighted the great length to which many of these students go to avoid any form of public speaking in a University setting and how this affects their learning. This article is an example of how internet-based surveys can be used to obtain in-depth qualitative information about delicate, embarrassing or stigmatising mental health difficulties and, as has previously been shown across a range of difficulties (e.g. sexual difficulties, addictions) the anonymity of the internet facilitates people talking openly about problems which they may find hard to do face-to-face.

A fascinating illustration of the world of online drug user forum communities is given by Davey et al. (2012, this issue). New recreational drugs, be they synthetic or herbal are constantly emerging, thus information through professional literature is often available only late or out-of-date. Drug-related internet forums often include highly educated and informed users with in-depth pharmacological and technical knowledge. The qualitative study of eight such internet forums offers insight into group language and culture, characterised by an ethos of sharing and support. Understanding these communities has the potential for gleaning new information on compounds consumed and methods of administration and can inform research, policy, clinical knowledge, treatment and preventative approaches.

Moessner and Bauer (2012, this issue) describe an anonymous online eating disorder counselling service offered free by a counselling centre in Heidelberg, Germany. The service includes both an online forum and email counselling. Of note the majority of people who used the programme had never had any professional help before. Many of these availed themselves of face-to-face treatment services for their eating disorder after using the email counselling, suggesting that a low-intensity service that is easily accessible and is perceived as helpful and non-stigmatising can be a stepping stone for more intensive treatment. This echoes earlier findings by Pretorius et al. (2009, 2010) in eating disordered adolescents the UK.

Technology-enhanced outcome monitoring, personalised feedback and the prospect of intelligent real-time therapy

The potential of longitudinal treatment outcome monitoring through use of ICT in general, and in relation to different technologies and systems (web-Akquasi, ecological momentary assessment and supportive monitoring, is described by Bauer and Moessner (2012, this issue). Such regular monitoring allows the study of the time course of, for example, different symptoms and their inter-relationship, the provision of feedback to therapists regarding clinically significant change, supportive feedback to patients, and ultimately the optimal use of treatment resources, by adapting intensity of interventions to clinical need.

Adding to this, Musiat et al. (2012, this issue) discuss how personalised feedback functions built into e- and m-mental health applications can be used to increase service users' motivation, highlight risks, change attitudes and go some way in addressing the lack of personal contact in computerised health interventions. The authors demonstrate how information from (multiple) assessments and/or data from comparable samples can be integrated into statistically supported and user-friendly feedback without including test scores and make recommendations for optimal use of feedback in e-health applications.

Extending these findings and ideas, and using the example of suicide prevention treatment, Kelly et al. (2012, this issue) discuss how through use of experience sampling methodology smartphone-delivered “intelligent” real time psychological therapy could be developed.

Therapeutic gaming

This is an area which is interesting not just for the therapeutic services but also for those who design computer games. At an ESCoNS conference last year it was clear that the Entertainment Software industry consider that they have overcome many problems in engagement of the general public with computer games and now they are set to deliver on an agenda for treatment for people with e-mental health especially for those whose cognition is compromised (see Entertainment Software and Cognitive Neurotherapeutics Society, www.escons.org). Computer games offer the potential for exploring and treating mental disorders playfully and interactively, presenting participants with scenarios relevant to their disorder and helping them to learn to remediate their problematic thoughts, feelings and behaviours. An example of such a serious video game, PlayMancer, for people with impulse control disorders (e.g. pathological gambling) is given by Fernández-Aranda et al. (2012, this issue). PlayMancer combines use of different video scenarios with real time monitoring of physiological and emotional reactions and biofeedback to teach participants to improve emotion regulation and impulse control.

Conclusions

It is clear that the present special edition can only offer a tantalising glimpse into the myriads of possibilities that are afforded by the advent of e- and m-mental health. To fully exploit the potential of e- and m-mental health, future applications will need to bring together neurobiological expertise with e-health expertise. Research into neuroimaging and neurocognitive bio-markers will increasingly facilitate the development and delivery of more targeted and personalised psychological treatments for people with mental health problems (Insel, 2009). While traditional talking therapies, such as cognitive-behavioural therapy (CBT), target effortful, “top-down” cognitive processes, novel approaches such as real-time functional magnetic resonance imaging (fMRI) feedback (Weiskopf, 2011), computerised attention bias modification (Hakamata et al., 2010) and cognitive training/cognitive remediation approaches (Rabipour & Raz, 2012; Wykes & Spaulding, 2011) target a range of neural processes, including those that are early and sub-cortical, and which may not be under conscious control, thereby opening up new therapeutic avenues. There are still more problems to overcome – the high drop-out rates for any self help treatment including e-therapy, access to the internet which is still not universal and the levels of computer expertise which is often related to poverty and increasing age. There are also exciting areas to explore such as the use of avatars and virtual reality to help to treat mental health problems. However, this issue of the Journal will show areas of growth which will stimulate more research in this area.