For all of the advantages of the Australian Healthcare system, like systems in other developed countries, our health system is under increasing pressure due to a shortage of trained healthcare professionals, suboptimal distribution of services and the increasing demand for care.As a result, our healthcare system is exposed to delays in accessing information and services.This leads to high levels of frustration amongst healthcare providers and clients - particularly disadvantaged groups, including those who are experiencing mental health disorders)This situation is compounded dramatically by the occurrence of comorbidity.
Australia was one of the first nations to recognise the potential and benefits of e-health, leading to a number of initiatives in the 1990s aimed at better integrating technology into practice.E-health approaches have been recommended in the newly released Guidelines on the management of co-occurring alcohol and other drug and mental health conditions (led by Kath Mills) and on the NSW Health Professional Practice Guidelines for Psychosocial Interventions in Drug and Alcohol Services.
All participants made significant improvements in their depression relative to baselineTherapist reduction = 18 points at 36/mthrel to baselineComputer = 14 pointsPCT = 11 pointsTrend towards the SHADE participants reporting significantly greater reductions in depression at 3-months (14-points) relative to the other treatment conditions (8-9 points)
This represents only those people (62%) who met criteria for hazardous alcohol use at baseline.Again, all participants made significant reductions in alcohol consumption relative to baseline. This reduction was greatest for the SHADE participants, although their baseline level of consumption was higher (although not significantly higher) to begin with.Relative to baseline, cac participants reported a 62% reduction in alcohol use at 3 years, Therapist compared to a 44% reduction for therapist cbt, PCT and in fact an increase of 18% among the pct groupSlight trend towards the SHADE participants reporting greater reductions in alcohol use relative to other conditions (especially at 3 months) – but not statistically significant, and may in fact be due to their high baseline consumption.
This represented a 25% reduction in binge drinling frequency for both cac and therapist cbt at 3 years relative to baseline, and a 3% reduction for the pct group
Relative to baseline, cac participants reported a 67% reductionin marijuana use at 3 years, compared with 44% in therapist cbt participants and 29% for the pct group.Interesting pattern of reduction over time for both PCT and SHADE – with an increase in cannabis use evident at 6-months relative to baseline.
Often, the evidence needed to encourage clinicians to support various e-health programs (SHADE included) and to adopt a proposed technology is not compelling, and in many cases is completely absent.2 dissemination trialsMental Health Service SettingEarly Psychosis Service Rob 10-week ProgramDrug and Alcohol Service SettingCounselling, Cannabis Clinic, MERITTanya Skill Modules
The failure to understand and effectively communicate the benefits of e-health has been a major impediment to the implementation of e-health in Australia and many other developed countries. But, with the right tools, sound, informed decisions can be made that are based on evidence and a clear understanding of how value can be created from e-health applications in different care settings.We hope that SHADE can go some way towards improving the current situation, if only for the important area of depression and substance use comorbidity.
Stepping out of the SHADEThe use of e-health approaches to the treatment of comorbid depression and alcohol/other drug misuse Frances Kay-Lambkin, Amanda Baker, Brian Kelly, Terry Lewin, Vaughan Carr The SHADE Project Centre for Brain and Mental Health Research National Drug & Alcohol Research Centre University of New South Wales, Australia
Depression and substance use comorbidity... Comorbidity is important because… Increases burden of illness and disability Negative mood cited most often as cause of relapse across a range of substances mild depression elevates the risk of relapse to drinking three-fold in comparison to people without depressive symptomatology Consistent association between suicidality, depression and alcohol use problems No clear treatment model Difficulties accessing treatment
Treating depression and substance use comorbidity Reducing the burden of disease involves developing and disseminating efficacious treatments Australia: 62% of people with mental illness do not seek any professional help. Stigma, economic, geographic disadvantage Even more the case with comorbid depression and problematic alcohol/other drug use Research sparse
Health System Challenges... “Increased health care service demands, costs and complexities are already testing the limits of the financial, physical and human resources of the Australian Health System...These challenges will not be solved by doing more of the same, particularly given the limits of available human and financial resources...” AIHW (2008) AHMAC (2008)
The potential of e-health to respond to these challenges... E-health = rapidly expanding field of health information and communication technology Widespread recognition within health sector that better use of e-health initiatives should play a critical role in improving the Australian healthcare system Increasing acceptance for individuals to take a more active role in protecting their health and participating in their own health care
The potential of e-health approaches Treatment can be accessible at times and in locations that suit clients May reduce stigma associated with treatment Clients can work at their own pace, tailoring the provision of information and strategies May be able to circumvent some of the challenges of treatment access Particularly for comorbidity
The potential of e-health approaches In Australia... 72% of households in 2009 reported home access to the internet In Canada... Current drinkers significantly more likely than abstainers to have at home internet access (73% vs 50%) Illicit drug users (cannabis and cocaine) report equivalent rates of home internet access to non-users
The SHADE Project Computerized, clinician assisted, combination CBT/MI for depression and alcohol/other drug use problems
The SHADE Project Developed in the Hunter (NSW) Project run in collaboration with Centre for Rural and Remote Mental Health (rural and urban) Target depression (and co-occurring alcohol use, cannabis use problems) Use CBT Compare face-to-face treatment with computer treatment (SHADE) with supportive treatment (PCT) Follow-up people up for 3 years
SHADE... Andersson & Carlbring (2009) “[SHADE] has the potential to fit in well with existing health-care services...” Key challenges in the uptake of e-health in clinical practice: Access to technology Reluctance of healthcare providers to adopt technology or change their practice without compelling reasons to do so Research trials attest to efficacy Lack of evidence from service-based dissemination trials Lack of understanding about the potential for e-health systems to augment health care DoHA-funded consultation Most common response by community was confusion (“online AA?”, “like MMN or something?”, “what, talking to someone online...?”)
So, what’s the upshot for e-health? ? Enhanced adherence to best (or evidence-based) practice ? Empowering clients to better manage their own health Can be applied to the complexities of comorbid depression and alcohol/other drug use ? Reduced time and cost addressing comorbidity Use of e-health initiatives may be a question of costs, client preference and provider preference