Proposal for the John Cade Fellowship

Introduction

The Hon Justice Annabelle Bennett AO, Chair of the NHMRC Council, asked the audience at a NHMRC Research Council dinner in Canberra, in 2012, the question: How could you transform the mental health of Australians? My interest was triggered immediately and my thinking ultimately ended with my ‘research application’ for a John Cade Fellowship about 8 months later. My answer to this question was that: The mental health of Australians will be radically transformed if it were possible to implement what we already know about preventing and treating the common mental health disorders. We have effective strategies, but too few Australians who could benefit are offered them. By harnessing Internet technologies, the aims of the Fellowship application were to test effective methods to implement proven prevention strategies at the population level and to increase help-seeking in those who need treatment.

In 2004, Gavin Andrews identified two areas with potential to achieve a reduction in the burden of common mental disorders – and by an astonishing estimated 45% (Andrews et al., 2004). These were to prevent depression (potentially resulting in a 22% reduction in burden) and to increase the rate at which those needing treatments actually receive them (an additional 23% reduction if fully implemented).

A central tenet of my Fellowship application was that technologies could assist and, indeed, accelerate translation in these two areas. Information communication technology (ICT) is increasingly recognised as a driver and transformer of health practice, including in psychiatry and psychology. In his recent report of medical health research in New South Wales, Wills (2012: viii) noted that these advances ‘position us at the start of arguably the most exciting era of health and medical research’. ICT is currently being used to deliver many e-health applications. These are effective in preventing and treating mental health conditions and the Internet serves as a platform to disseminate them. Pervasive personal health devices, such as those installed within mobile phones, can be used to collect individual data on risk factors, and thus offer for the first time the potential to collect individual data and develop personalised, tailored programs delivered universally. The Internet also provides the opportunity for fostering social connectedness, through social media sites, such as Facebook, Instagram, tweets, emails and SMS. These social networking modalities can be studied, harnessed and influenced, thereby creating a unique opportunity to change attitudes and bring about behavioural change at a population level.

The prevention of depression and going ‘to scale’

The prevention of depression is a new and small research field. Although there are only 32 ‘genuine’ randomised controlled prevention trials, they clearly show that depression can be prevented (Cuijpers et al., 2012). Most ‘indicated’ prevention programs use interventions effective in treatment, such as cognitive behavioural therapy (CBT). More recent trials focus on vulnerability rather than symptoms, and use more sophisticated approaches to target people before they are symptomatic – either by delivery prior to major life transitions, such as those that occur when undertaking new jobs, starting new schools, taking up new roles (such as caring for someone with cognitive decline); or by building cognitive skills in individuals with one or more risk factors (such as family environment or exposure to trauma), or with ‘constitutional’ characteristics, such as anxiety sensitivity.

Into the future, the field of prevention will expand. Moves towards universal preventive approaches to the common mental health disorders at a population level, such as research investigating the role of diet (Jacka et al., 2012), together with the lessons learned from the public health successes of reducing smoking and lowering cardiovascular disease over the last 20–30 years, will create new generational prevention initiatives. Modifications of our environment to induce exercise, healthy eating habits, etc., for both physical and mental health, may be key to these new efforts. However, right now, the best that can be ‘guaranteed’ in the way of prevention is to deliver treatment interventions.

Putting this into practice is challenging – as delivery with fidelity and compliance across the population at large is required. To research effective universal prevention, 20,000 or more participants are required to demonstrate effects (Munoz, 2010). If ‘treatments’ are the only effective interventions we have currently, the roll out of these to the masses raises huge problems – the mental health workforce is simply not and can never be large enough for a start. The solution to the ‘roll out’ is to use e-health technologies; specifically, online Internet programs that offer CBT. Schools provide an unprecedented opportunity to reach almost all children. The first research projects for the John Cade Fellowship will involve implementation trials in school. One large-scale prevention trial of 20,000 individuals (400 schools) will deliver an online CBT program via the Internet. Data will be collected by self-report, but also by wearable sensors and mobile phones. The trial has the potential to understand predictors of emerging psychiatric disorder, as well as predictors of ‘prevention response’. It will encourage development of sensor and mobile phone technology, as well as offer, develop or use state-of-the-art interventions, such as games, and create a data set that offers opportunities at all stages of research, using a cross-disciplinary team.

Increasing evidence-based treatments to those who do not seek help

A large proportion of people with mental health problems do not seek help. Help-seeking will increase if stigma is lowered (Link and Phelan, 2006). Evidence is emerging as to the conditions that will reduce stigma (Corrigan, 2011). The principles of Corrigan’s theory of strategic stigma change are defined by the acronym ‘TLC’: Targeted, Local, Credible and Continuous contact. However, implementing stigma reduction at a population level is likely to be a challenge. This Fellowship argues that social media may be a platform that might contribute to reducing stigma. The core characteristics of social media are that communication can be within existing ‘local’ communities, consisting of similar ‘targets’, offering relatively stable levels of continuous contact, and consisting of credible participants. However, further research is required to understand the best approach and methods. The Fellowship will begin to investigate a range of media technologies that could be used to lower stigma and increase help-seeking. Questions to be asked include: What messages/online behaviours will lead to attitude and behavioural change? What network connections will lead to greatest influence? Who is best to transmit these messages? What research designs are required/possible to establish this knowledge? What technologies are suitable: Twitter, Facebook, etc.; and what tools are required to ‘scrape’ Facebook or analyse tweets?

Building blocks and strategy

To achieve this research agenda, four key elements will need to be developed and achieved. These are, first, to establish a Translation Centre in E-Health, which will bring together expertise in behavioural change, technology, social theory, media, marketing and translation. This centre, currently dubbed ‘Digital Dog’, will be launched mid-2014. A second element is to adopt a translational model to assist in taking the research to scale. A ‘hub and spokes’ model based on the work of Lomas at the Canadian Health Services Research Foundation will be used for this purpose (Russell et al., 2009). A third element is to train research scientists across multidisciplinary fields and to provide skills in developing and relating to industry, technology and mental health services. A final element will be the collaboration to achieve the technologies and skills needed. Thus, a core aim of Digital Dog will be to establish relationships with industry, research institutions, a research group in ethics, and communication and dissemination organisations. The program has established collaborations with US online developers, Australian communication and media groups, health care providers in Australia, and the St James Ethics Centre. Research collaborations include Professor Gunther Eysenbach, Centre for Global eHealth Innovation, Consumer Health & Public Health Informatics Lab, University Health Network, and the Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada; and Professor David C Mohr, PhD, Professor in Preventive Medicine, Medical Social Sciences and Psychiatry and Behavioural Sciences, Chicago. Dr Mohr’s work lies at the intersection of behavioural science, technology and clinical intervention research. This collaboration will bring expertise in the use of mobile phones as sensors and monitoring tools.

In closing

The ideas of preventing disorder and increasing help-seeking are neither radical nor new. The translational directions of this Fellowship are consistent with the outcomes of recent reviews of scientific research (Department of Health and Ageing, 2013; Wills, 2012), which focus on translation rather than discovery as a priority. However, the challenge of this Fellowship is to demonstrate that implementation of translational gaps is achievable, and that the measures put into place under this Fellowship have impact. To be the recipient of this Fellowship is simultaneously thrilling and terrifying: thrilling because a substantial proportion of the Fellowship is entirely new and will pursue new directions, and terrifying for exactly the same reason.