Monash University researchers have studied how the introduction of tele-mental health services in Gippsland during the pandemic and associated lockdowns in particular helped young adults, First Nations people and those with ongoing anxiety requiring ongoing support – as some of the groups that most benefited.
In response to this increased need for tele-mental health services during COVID, Victorian Primary Health Networks (PHNs), including Gippsland PHN, implemented a free centralised intake service with several novel elements, such as tele-health and stepped care, which is a staged intervention depending on a patient’s individual needs.
A study led by Monash School of Rural Health researchers in Warragul and published in the International Journal of Environmental Research and Public Health, examined the views and experiences of clinicians and service users of the tele-mental health service in the Gippsland region of Victoria during the COVID-19 pandemic.
In the study, data from 66 clinicians and service users were obtained via online surveys and interviews – revealing six major themes:
- Conditions where use of tele-mental health is appropriate
- Conditions where tele-mental health may not be useful
- Advantages of tele-mental health
- Challenges in using tele-mental health
- Client outcomes with tele-mental health
- Recommendations for future use.
According to lead author, Dr Anton Isaacs, the study “is one of only a few where clinicians’ and service users’ views and experiences have been explored together to provide a nuanced understanding of perspectives on the efficacy of tele-mental health when it was implemented alongside public mental health services,” he said.
Dr Isaacs said that, traditionally, when telehealth was used in place of face-to-face mental health services, “not being present with the patient experiencing a crisis has been suggested as a significant and potentially precarious situation,” he said.
“The pandemic, with the broad roll out of tele-mental health services, provided a unique opportunity to determine what types of interventions are effective, for which patients and in which settings, and whether such interventions can be used as a replacement for the standard treatment and in fact, whether or not tele-mental technologies are associated with any harm also needs investigation.”
The Royal Commission into Victoria’s mental health system states in their report that mental health services in the state of Victoria are ‘broken’ and a large group of individuals have been left with unmet needs for services and the Gippsland region is no different.
“These people were termed the ‘missing middle’ – a group of individuals who are too unwell for primary care but not unwell enough for specialised mental health services,” Dr Isaacs said.
In 2020 the state of Victoria implemented a tele-mental health model within the broader Head to Health (H2H) initiative. A collaboration between the Australian government and the Primary Health Networks, the H2H program was a free centralised intake service and had four key elements: Referral, Assessment, Treatment, and Follow-up.
Referral was via a toll-free number. The referring doctor – most commonly a GP – would speak to a mental health professional who assessed the client’s needs using a specifically designed screening tool and refer them to the appropriate level of care. Using a logic algorithm, the tool recommends the level of care needed for the patient according to the stepped care approach with clients referred to one of five different levels of care depending on the severity of their illness. Level 1 care recommended self-management for clients with minimal problems and Level 5 involved referral to acute specialist or community mental health services for clients with very severe problems.
Of the 47 clinicians surveyed three quarters were women and over half have worked in Gippsland’s mental health and wellbeing service sector for 10 years or more and over 72 per cent had provided mental health care in Gippsland (72.3 per cent).
The study found:
- clinicians and users indicated that H2H was much more accessible for those who resided in geographically isolated areas
- H2H was particularly useful in enabling access during the lockdown period to both clinicians and users
- clinicians stated that given the general paucity of mental health services and the high unmet need in the region, H2H was very welcome
- clinicians found H2H to be effective for young adults and those who were able to independently set up and use technology
- clinicians also indicated that the model worked well when there was an organisational commitment to using the technology
- tele-mental health technology was useful when clients had anxiety, were working on maintaining recovery, and with whom there was a pre-existing therapeutic relationship
- clinicians also used tele-mental health to stay connected with their clients
- Aboriginal service users in particular, who typically experience a lack of appropriate services, had high praise for this mode of service delivery.
However, the study also reveals conditions where tele-mental health was found to be unhelpful, according to co-author, Dr Keith Sutton. “Clinicians felt that it was not conducive as a service for individuals who could not afford a phone or internet or for those who belonged to culturally and linguistically diverse (CALD) communities owing to language barriers,” he said.
Dr Sutton added that assistance from their clinician also assisted in people from a CALD background overcoming their concerns about technology, their accent and language skills and concerns over privacy.
Other concerns raised about tele-mental health:
- there is a barrier to its use by clients from certain smaller rural towns
- is not helpful for children who required hands-on therapy activities or for older clients who were not familiar with using technology
- not appropriate when working with clients in distress who needed immediate human connection and for those who were at risk of self-harm
Advantages of tele-mental health over face-to-face delivery:
- improved accessibility in that it could be delivered in the safety and familiarity of the home, and clients did not have to travel long distances to see a specialist
- less delay in seeing a clinician
- more privacy – which can be a significant issue in rural and remote locations
- clinicians stressed the advantage of being able to phone clients even when the latter had forgotten the appointment as did service users who forgot appointments.
From the results of the study the authors recommend that tele-mental health
- is best suited for client–practitioner interactions when there was an existing therapeutic relationship between them
- is best used as part of a ‘dual mode’ of delivery rather than a stand-alone model because it could not take the place of face-to-face interactions
- There needs to be communication with clients, prior to the commencement of the session, about the use of technology and how the service would work.