The challenge of routine follow-up in e-mental health services

To the Editor

Despite the exponential growth of e-therapy in Australia, few services are evaluated. Indeed, Jorm et al. (2013), in a recent editorial on the future of e-mental health, suggest evaluation is challenging, as practice is moving faster than the evidence base can be established. We recently explored client responsiveness to a follow-up email after a single session of web-based counselling for problem gambling (www.gamblinghelponline.com). Follow-up was provided to all clients except those who actively elected to opt-out (i.e., unchecked the box). While 80% did not opt out, only one in five (22%) responded to a follow-up email despite multiple requests (up to three emails). The survey was administered between one and 10 weeks following the initial session, with the highest response rate (35%) evident when clients were contacted three weeks after the initial session.

Clients were invited to address queries or requests for further assistance via email to administrative staff. Of the 73 clients who responded (out of possible 331 (22%)), 60 clients provided a qualitative response in addition to completing a brief evaluation. Frequently, clients expressed appreciation of follow-up, which was variously perceived as uplifting, empathic, caring and supportive (68%). A surprisingly profuse response was received from clients who used it as an opportunity for self-reflection with almost 48 out of 60 (80%) providing unprompted information on their goals, plans and priorities, as well as action taken since their initial contact with the service, which had not been requested.

This evaluation identified multiple issues related to follow-up in an e-mental health service. First, 33% of those who responded requested additional information or help in managing their gambling problem. Second, some clients required an immediate clinical response (i.e., low mood and possible self-harm reported). Third, there were a high number of emails that bounced, as well as extended periods of time between follow-up and response (explained as holidays, not checking emails, finishing employment or just being busy).

While client follow-up is logistically easier to deliver and receive online, it imposes new challenges in terms of obtaining a reasonable response rate. The findings of this evaluation suggest follow-up often requires a clinical response as well as helping clients reconnect with services. Future evaluations should consider building in therapeutic support options at every client contact, especially given low response rates within community settings.