Internet interventions based on MHL

Emails, websites and online programs appear to be the intervention types most often used to improve MHL, and can address individual or multiple aspects of MHL. These appear to be psycho-educational in nature, although some are based on relevant behaviour change or help-seeking theory (Gulliver, Griffiths, Christensen, & Brewer, 2012). MHL interventions may also alter stigmatising attitudes and beliefs towards mental health and help-seeking (Clement et al., 2015).

59 Costin et al. (2009) delivered a brief email-based intervention (‘e- cards’), developed through applying the four-stage help-seeking model (Rickwood, et al., 2005); the e-cards’ content was designed to change salient factors affecting help-seeking (e.g. improving persons’ recognition of depression, changing perceptions of treatments). Through an RCT, these e-cards were compared to another e-card intervention (basic and less intensive information) and an attention-placebo control group. A sample of Australian young adults (n=348, 19-23 years), screened into “low” and “high” distress groups, were randomly assigned to these conditions and received three e-cards over a three week period. Participants’ beliefs about help-seeking, related intentions and behaviour, ability to recognise depression and help-seeking knowledge, were assessed at baseline and post-intervention. Post-intervention, the intervention had no effect upon help-seeking behaviour from informal and formal sources, but did improve intentions to seek help from formal sources, regardless of participants’ level of psychological distress. Compared to controls, participants who received the less intensive e-card were more likely to endorse at least one health professional as ‘helpful’. There were no associations found between conditions and treatment beliefs, helpfulness of informal sources, or ability to recognise depression. The majority (>90%) reported each intervention e-card as ‘helpful’, with a similar percentage (>83%) endorsing helpfulness of the basic e-card. Participants may not have perceived the e-cards’ content to be relevant to them at that point

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in time, meaning they would not have sought help regardless of intervention exposure. Costin et al. state that their findings converge with previous trials which suggests information alone appears insufficient in changing behaviour and altering participants’ perceptions of their psychological distress. However the short-term follow-up could explain this limited change; at six-week follow-up, another email-based intervention reported decreases in sub- threshold depression (Morgan, Jorm, & Mackinnon, 2012).

Web-based interventions may be a particular avenue to explore; compared to just emails, websites can provide a wealth of content in one centralised place, and can address many aspects relating to MHL. Barak, Klein & Proudfoot (2009) define web-based interventions as “a primarily self-guided intervention … that is

executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental health-related assistance. The intervention … attempts to create positive change and/or improve/enhance knowledge, awareness and understanding via the provision of sound health- related material and use of interactive web-based components”.

Even within this category, Barak, Klein & Proudfoot (2009) define three levels of web-based intervention which differ slightly in their content, use of multimedia, interactivity and human support (see Table 2). Below, two website, theory-based MHL-related interventions are described in more detail. These two were chosen due due to their use of theory in their development, and they have

61 Table 2. Categories of the three different subtypes of web-based internet interventions, as defined by Barak & Grohol (2011).

Subtypes of web-based internet interventions Components Web-based education interventions Self-help web-based therapeutic interventions

Human support web- based therapeutic

interventions

Program content

Inactive education content, largely non-

prescriptive and standardised educational content

Structured content designed to change behaviour. Designed to be treatment/prevention/promotion to attempt to create positive cognitive, behavioural or

emotional change

Multimedia use

Primarily static - may use minimal different types of multimedia to communicate content

Interactivity Primarily static - may range from zero to two interactive activities for users Feedback

and human support

Typically zero or partially automated

support, but may vary depending on intervention - can range to moderate or high levels of automated or human support None or partially automated support - no tailored feedback to participants, or receives automated feedback (e.g.

diagnostic feedback, reminders). This may vary by intervention - level of feedback is on spectrum of intensity and

specificity

Partial human support: level of support is on a spectrum of intensity, ranging from minimal

provision (e.g. reminders, support to use intervention) to high

provision (e.g. regular contact providing distance or face-to-face

feedback and support)

both received some user evaluation.

1.6.2.1 MoodGym, a CBT-based website

MoodGym (a CBT-based website) and BluePages, a website

providing information about depression and treatments, are two freely-available online resources. These interventions address several depression literacy components (e.g. knowledge about

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depression, treatments, self-help); both through MoodGym itself as it is a self-guided CBT program, and also through promoting other self-help strategies. A systematic review of twelve trials of

MoodGym and BluePages with adults and adolescents supports their

use in decreasing depressive and anxiety symptomology, and also improved adult’s depression literacy and use of evidenced-based treatments (Griffiths & Christensen, 2007). Taylor-Rodgers & Batterham (2014) synthesised content from other evidenced-based anxiety, depression and suicide awareness sources to produce a brief psycho-educational website designed to improve MHL literacy, stigma, help-seeking attitudes, and intentions, and compared it an attention control. An RCT involving Australian university students over a three-week period found those

assigned to the psycho-educational website reported greater reduction in stigmatising attitudes, and improved changes in help- seeking attitudes and intentions to seek help from a GP, compared to controls. Improvements were only found for anxiety literacy, which may be because depression literacy was fairly high at baseline. The authors comment that interactive content (e.g. decision-making tasks) and videos may help increase participant engagement, and could help further improve outcomes.

1.6.2.2 ReachOut.com, a website-based mental health resource

Based upon the four-stage process framework model (Rickwood, et al., 2005), ReachOut.com is a website developed by Australian

63 researchers as a form of health promotion, prevention and early intervention for young people. It is Australia’s leading online resource for mental health information, with over seven million people having accessed it since its inception in 1998 (Nicholas, 2010). Through providing a vast resource of credible information delivered through several multimedia formats, as well as incorporating a CBT-based game, the website is designed to improve young people’s MHL, recognition of symptoms/signs of mental health problems, help-seeking behaviour, resilience and social connectedness with others (Collin et al., 2011).

ReachOut.com acts as a ‘gateway’ in helping young people recognise

whether they have a mental health problem which requires intervention, and provides support for them to access appropriate help. The original ReachOut.com has been adapted for Irish and American audiences (e.g. information about professional help is relevant to each country), and all are freely available to anyone with internet access.

ReachOut.com appears to be helping improve young people’s MHL

and related help-seeking behaviour (Nicholas, 2010). A cross- sectional survey of users (N=2291) reported the website helped their knowledge of mental health problems and the help available, as well as improving understanding of their feelings (Collin, et al., 2011). Over a third (35.2%) stated the website had helped them to some extent in seeking out professional help, while a large proportion (43.3%) stated it had helped them increase their

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confidence, skills and knowledge needed to seek out help. Over half (53%) of those screening for elevated distress stated they accessed

ReachOut.com due to their current symptoms and were looking for

help. A ‘one-stop’ website allows developers to put content relating to the multi-faceted nature of MHL into one place, and compared to traditional leaflets/booklets, may be more accessible to young people given its ease and privacy of access. Likewise these websites may be in line with young people’s preferences for self-reliance. Interventions could also alter perceived social norms about mental health and help-seeking to challenge stigmatising attitudes, as students may over-estimate the perceived presence of stigmatising attitudes in others and often perceive themselves as having low levels of stigma (Downs & Eisenberg, 2012).