Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697644909058.pdf (Australia)
Productivity Commission Inquiry The Social and Economic Benefits of Improving Mental Health Submission prepared by ReachOut Australia April 2019 Contents Executive summary ........................................................................................................................................... 2 Recommendations ......................................................................................................................................... 3 Young people and the consequences of mental ill-health ................................................................................. 4 The effectiveness and cost of ReachOut........................................................................................................... 5 Research and evaluation framework ............................................................................................................. 6 ReachOut (Peer Support) Forums ................................................................................................................. 7 ReachOut NextStep ....................................................................................................................................... 8 Innovation agenda ......................................................................................................................................... 9 ReachOut Schools ....................................................................................................................................... 10 Gaps in current programs and supports .......................................................................................................... 10 Effectiveness of alternative programs and supports ....................................................................................... 11 Previous findings and recommendations ..................................................................................................... 11 What do young people want from a mental health service?
........................................................................ 14 What digital technologies offer?
.................................................................................................................. 16 Adding capacity to the mental health system and prevention through digital technologies ........................ 18 Conclusion ....................................................................................................................................................... 20 Contact......................................................................................................................................................... 20 Helping all young people be happy and well.
Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Executive summary Nearly half of all Australians will experience a mental health problem over the course of their lives.1 Timely and appropriate help-seeking, especially during adolescence, can reduce the long-term health, social and economic impact of many of these mental health problems,2 yet studies continue to show that the majority of people experiencing a mental illness don’t get the help they need.3 This problem is especially pronounced among young people, with 70 per cent of young people who experience a mental illness receiving no help.4 Supporting the mental health of our population has the attention of governments at all levels.
As well, the need to improve help-seeking rates is well recognised.

However, improving help-seeking rates is undermined by barriers to access and capacity constraints in the current mental health system.

There is no question that additional funding is required to build the capacity of existing services.

However the current size of the gap between the demand for mental health services and supply shows that we must also find new ways to use existing resources and technology to help more people.
There is also a case for an increased focus on the prevention of mental disorders, to reduce the overall burden of mental illness and demand on services.

The Productivity Commission is investigating how to improve population mental health to realise benefits from increased social and economic participation and contribution to the wider community.
There are four streams of assessment including the consequences of mental ill-health; the effectiveness and cost of current programs and supports; gaps in the current programs and supports available; and likely effectiveness of alternative programs and supports.
ReachOut, supported by EY and Future Generation Global Investment Company (ASX:FGG) has undertaken a program of research and released a series of reports that explore the social and financial costs of mental ill-health; consider cost-effective solutions for system reform through online service delivery; and that help better understand young people’s mental health and service needs.
This submission has drawn on the following reports:  ReachOut and EY, 2013, Crossroads: Rethinking the Australian Mental Health System  ReachOut and EY, 2015, A Way Forward: Equipping Australia’s Mental Health System for the Next Generation  ReachOut and EY, 2016, One Click Away?
Insights into mental health digital self-help by young Australians  ReachOut and Mission Australia, 2018, Lifting the weight: Understanding young people’s mental health and service needs in regional and remote Australia (ReachOut research supported by FGG).

The full reports are accessible at https://about.au.reachout.com/us/our-research/ 1 Slade T., Johnston A., Teesson M., Whiteford H., Burgess P., Pirkis J., and Saw S., 2009, The Mental Health of Australians 2.
Report on the 2007 National Survey of Mental Health and Wellbeing, Canberra, Department of Health and Ageing.

2 Rickwood D., Deane F.P.

and Wilson C., 2007, When and how do young people seek professional help for mental health problems?, Medical Journal of Australia, 187:S35-S39.

3 McLennan W., (1998), Mental Health and Wellbeing: Profile of Adults, Australia 1997, Canberra, Australian Bureau of Statistics.
4 Australian Bureau of Statistics, 2008, National Survey of Mental Health and Wellbeing: Summary of results, 2007, Cat no 4326.0.

2 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Thank you A big thank you to all the young people who have given their time, and shared their insights and stories to make the ReachOut service what it is today.
Nobody knows young people’s lives, experiences and needs better than young people themselves and this is why you are at the centre of everything we do.
Recommendations – Recommendation 1: re-examine the advice of the National Mental Health Commission in its report Contributing lives, thriving communities: Review of Mental Health Services and Programmes including: to shift funding priorities from treatment and crisis, to early intervention, prevention and recovery, supported by innovative service delivery models that integrate digital self-help to develop the next generation of digital mental health services, that moves away from a system of stand-alone services, to one that integrates across services and sectors.
– Recommendation 2: as committed in the Fifth National Mental Health and Suicide Prevention Plan, develop a National Digital Mental Health Framework that will guide investment in and funding of digital mental health services and programmes, reduce duplication, and support digital mental health services to be used as a legitimate component of a stepped care model.
Recommendation 3: ensure a range of different types of services are available for young people and that meet their service needs and preferences, and to help overcome barriers to help-seeking.

Recommendation 4: trial the integration of youth-focused digital mental health tools and services with face- to-face youth mental health services.
Recommendation 5: in the short term increase investment in digital technologies to increase access and add capacity to the mental health system, and expand prevention programs.

Recommendation 6: in the long term develop and build a new, scalable, effective and integrated 21st century mental health care model.
3 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Young people and the consequences of mental ill- health Many young people in Australia are experiencing, or have experienced, a mental health issue and these rates are growing.
Just under one in four adolescents aged 15 to 19 years live with a probable serious mental health illness, and there has been a significant increase in the proportion of young people meeting this criteria over the past five years, rising from 18.7 per cent in 2012 to 22.8 per cent in 2016.5 Mental health disorders, such as depression and anxiety, experienced by this age cohort can cause a range of negative effects to wellbeing, functioning and development, both in the short and long term.6,7 These disorders also put young people at greater risk of suicide.
The number of deaths by suicide of young Australians is the highest it has been in ten years.8 Of great concern is that in 2017, suicide accounted for over one-third of deaths among 15 to 24 year-olds.9 One in four 15–19 year-olds lives with a probable serious mental illness.

75 per cent of mental health problems first appear before the age of 25.

More than 70 per cent of young people who need help and support don’t get it.

Timely and appropriate help-seeking is critical.


The high prevalence of youth mental health issues is acknowledged as an area of major concern for young Australians themselves.
Forty-three per cent of young people identified mental health as an important issue facing Australia today.10 For young people with a probable serious mental illness the top three issues of concern were coping with stress, school and study problems and depression.11 Despite recent developments in the delivery of services including significant investment in headspace, a national network of youth-friendly community-based centres, mental health issues among young Australians remain at high levels.
Half of all mental health disorders emerge by the mid-teens, while 75 per cent have their onset prior to age 25.12 These statistics underscore the need for effective prevention and early intervention programs targeting young people.
Seeking help early in symptom development is critical to reducing both the severity and duration of mental health problems.13 However more than 70 per cent of young people experiencing mental disorders don’t access any professional support,14 and studies show the median delay between the onset of symptoms and treatment for common mental disorders may be as long as ten years15.
Without appropriate support, mental health problems often increase in severity and can lead to social withdrawal, the breakdown of relationships and poor education and employment outcomes.16,17 In addition to these significant personal costs, economic 5 Mission Australia, 2017, Youth mental health report: Youth survey 2012–16.
6 Scott J., Fowler D., McGorry P., Birchwood M., Killackey E., Christensen H. and Hickie I., 2013, Adolescents and young adults who are not in employment, education, or training, BMJ, 347.

7 McGorry P.D., Goldstone S.D., Parker A.G., Rickwood D.J., and Hickie I.B., 2014, Cultures for mental health care of young people: an Australian blueprint for reform, The Lancet Psychiatry, 1 (7), 559-568 8 Beyond Blue, 2018, Stats and facts, Youth Beyond Blue.
9 Australian Bureau of Statistics, 2018, 3303.0 Causes of death, Australia, 2017.

10 Mission Australia, 2018, Youth Survey Report 2018.

11 Mission Australia, 2017, Youth mental health report: Youth survey 2012–16.

12 Kessler R.C., Amminger G.P., Aguilar-Gaxiolas X., Alonso J., Lee S and Ustun T.B., 2007, “Age on onset of mental disorders: A review of the recent literature”, Current Opinion Psychiatry, 20(4):359-364.
13 McGorry P., Parker A. and Purcell R, 2006, Youth mental health services, InPsych, August.

14 Australian Bureau of Statistics, 2008, National Survey of Mental Health and Wellbeing: Summary of results, 2007, Cat no 4326.0.

15 Jorm A.F., 2012, Empowering the community to take action for better mental health, American Psychologist, 67(13):231-243.
16 Cornaglia F., Crivellaro E. and McNally S.,Mental Health and Education Disorders, 2012, London: Centre for the Economics of Education, London School of Economics.
4 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health analysis undertaken by ReachOut and EY found that mental illness in young people aged 12 to 25 costs the Australian economy $6.29 billion a year18, while a 2009 Access Economics report put the financial cost of mental illness in people aged 12–25 at $10.6 billion a year19.
The effectiveness and cost of ReachOut ReachOut is Australia’s leading online mental health organisation for young people.

Available 24/7 and accessible from just about anywhere, the service includes practical support, tools and tips to help young people get through anything from everyday issues to tough times.
ReachOut co-designs programs and products with young people, ensuring that the evidence-based digital tools, and information and support a young person accesses on ReachOut are relevant and delivered in a way that makes sense to them.

ReachOut has around 40 employees that work across service delivery, research, digital, marketing and communications, fundraising and operations.
ReachOut works with a Clinical Advisory Group, a diverse team of clinicians, who advise on best practices in mental health service delivery.

With the Clinical Advisory Group, ReachOut designs and refines features of the service and to respond to trends and changes in mental health policy and practice.

ReachOut offers immediate support that is low cost and high scale at ReachOut.com and through other channels eg social media.

ReachOut leverages government investment with other revenue streams.
ReachOut is a gateway to relevant and personalised mental health information, resources and services.

One in two young people that visit ReachOut experienced an improvement in symptoms over a three month period.

ReachOut’s innovation agenda has a focus on personalisation, integration of peer support, reducing duplication and cost inefficiency across the sector.

In 2018, 2.4 million Australians visited ReachOut.com or around 200,000 people every month.
In 2017–18 ReachOut received core funding of $1,606,632 for ReachOut.com (Youth) from the Australian Government Department of Health, Telephone Counselling, Self Help and Web-based (Teleweb) Support Programme.

ReachOut also receives funding from the Australian Government Department of Social Services to operate the ReachOut Parents service, as well as from ad hoc government programmes and initiatives.

ReachOut leverages government funding with other revenue streams.
Total funding from government in 2017–18 was $4,829,483 (57 per cent of total revenue) and ReachOut received $3,369,131 (40 per cent of total revenue) from non-government grants, donations and fundraising, see Table 1.

Table 1: ReachOut revenue 2017–18 17 Olesen S.C., Butterworth P., Leach L.S., Kelaher M. and Pirkis J., 2013, Mental health affects future employment as job loss affects mental health: Findings from a longitudinal population study, BMC Psychiatry, 13:144.
18 Hosie A., Vogal G., Carden J., Hoddinott J. and Lim S.,A way forward: Equipping Australia’s mental health system for the next generation, 2015, EY and ReachOut Australia.

19 Access Economics, 2009, The economic impact of youth mental illness and the cost effectiveness of early intervention.
5 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health ReachOut’s information and digital support is accessible online at ReachOut.com and also through other channels eg social media.
In addition ReachOut has developed a range of innovative programs and tools that extend its reach and impact, including:  ReachOut (peer support) Forums: established in 2007 it is one of the most active and best established online youth mental health forums in Australia and globally.

ReachOut Forums offers peer support by both formally trained peer moderators and informally between members.
 ReachOut Next Step: a tool that recommends customised support options based on a young person’s symptoms and how significantly the symptoms are affecting them.

Support options include articles, apps, forums, and online, face-to-face or phone counselling.

Referral issues include mental health, alcohol, drugs, bullying and much more.

To me personally, ReachOut is something I can always turn to if I am struggling, it's a place where I don't feel like a burden for asking for help.
2017 Annual Survey  Apps and Tools: a digital tool that recommends mental health and wellbeing apps and digital resources that have been endorsed by both professionals and young people.

It includes three apps that have been developed by ReachOut: Recharge (managing sleep), WorryTime (managing worry/anxiety) and Breathe (managing stress and anxiety).
 ReachOut Parents: provides information, tools and resources to help parents and carers support 12–18 year-olds in their family environment; and includes an added option of coaching, delivered through a partnership with The Benevolent Society, to give parents concerned about their relationship with their teenager additional one-on-one online support.

 ReachOut Schools: offers support to teachers and other education professionals to build young people’s wellbeing and resilience.
Research and evaluation framework ReachOut has an in-house research and evaluation team with two main functions: 1) user and design research, to inform the delivery and development of our service offering 2) program evaluation, to generate insights to support the improvement of the services, gather evidence around the impact of our service, and build the evidence base around digital help more broadly.
In 2016 ReachOut reported on its inaugural cohort study.20 The study was one of the largest and most advanced of its kind and used online tracking methods to follow 1,953 consenting participants aged 16–25 across three months.
Chart 1: Cohort study change in Depression, Anxiety and Stress Scores (DASS) scores 48.2 e g a t n e c r e P 60 50 40 30 20 10 0 22.2 17.2 12.5 Overall better Overall worse No change Mix of up and down Cohort study: change in Depression, Anxiety and Stress Scores (DASS) 20 Vogl G., Ratnaike D., Ivancic L., Rowley A., and Chandy V., 2016, One Click Away: Insights into Mental Health Digital Self-help by Young Australians, Sydney: EY and ReachOut Australia.
6 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health The data showed there was a mix of one-off and repeated visitation to ReachOut among the participants.

Young people most commonly found ReachOut through organic online search and through school, although some were referred by health providers and others.
The most common time of visitation was after hours, when primary care services are not available.
Although ReachOut content and delivery aims to assist young people with mild to moderate problems, the cohort data showed that a range of young people access the service at different points in the help-seeking journey: – 24.7 per cent of participants had no prior visit to a mental health professional and no prior hospitalisation for a mental health issue – 59.4 per cent had a prior visit to a mental health professional but no prior hospitalisation for a mental health issue – 14.4 per cent had a prior visit to a mental health professional and a prior hospitalisation for a mental health issue.
Young people visiting ReachOut also experience differing levels of psychological distress from ‘normal’ through to ‘severe’.
The study found that ReachOut reaches a group of young people in high distress who have no previous formal help-seeking experience, with 56.3 per cent of those with no prior visit to a mental health professional and no prior hospitalisation for a mental health issue scoring ‘severe’ on the Depression Anxiety and Stress Scale (DASS) and 18.2 per cent at ‘high risk’ of suicide based on their Suicide Ideation Questionnaire (SIQ) score.
While young people across the study accessed a broad range of content, the majority of them came to ReachOut for support with anxiety (30.4 per cent) and depression (34.5 per cent).

Two out of three young people said ReachOut gave them practical suggestions and tools, and around 70 per cent said ReachOut made it easy for them to take steps to help themselves.
Of the 1,953 young people who participated in the cohort study, around 50 per cent (or 1 in 2) experienced an improvement in symptoms (based on change in DASS scores) over the three month time period, and those who were classified as severe or extremely severe showed the most improvement, see Chart 1.

ReachOut (Peer Support) Forums Peer support is an impactful, yet often underutilised component of Australia’s mental health support system.
Peer support amongst young people can help to validate their concerns, increase a sense of hope and aspiration for the future, and increase access to formal supports.

It has also been shown to reduce hospital re-admissions when incorporated as part of a discharge and recovery plan.
Most formal evaluation of peer support models has been undertaken in a face-to-face setting, yet there is increasing evidence that digital peer support, when supported by robust risk management infrastructure, can play a valuable role in supporting young people experiencing the early stages of mental health difficulties as well as those experiencing more acute risk.
The scale, access and cost-effectiveness that digital peer support affords suggests that this will be a vital component of a future system of mental health support.

I remember finding it quite helpful to hear that there were people out there who sounded like they could really relate to what I was going through.

Female, 23 ReachOut has facilitated digital peer support via an online community for over 10 years.

When ReachOut Forums launched in 2007, it was the first of its kind.
Since then, ReachOut has advised mental health organisations, in Australia and in other countries, on delivering effective and safe peer communities that put young people at the centre of their support and are underpinned by robust risk management procedures.
7 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health ReachOut’s peer support community now has over 10,000 registered members, who engage in discussions from everyday wellbeing through to tough times.

For the period July 2018 to December 2018 there were 144,744 unique visitors to the forums, i.e.

people who visit the Forums to read content without registering.
As the peer support community has evolved, ReachOut has worked alongside academics and engineers at the University of Sydney to develop Moderator Assist, a tool that uses natural language processing and AI, to assist with risk identification and management.

ReachOut continues to make enhancements to the tool and refine the natural language model, working with researchers at the University of Technology, Sydney.
ReachOut recently completed an evaluation of its peer support community with a cohort of young service users.

The study demonstrated the immense benefits of the program for young people that engage with the peer support, including: • • • • reduced isolation (particularly for young people who have limited social connections) improved self-confidence improved emotional and mental health literacy increased confidence and skills to access professional mental health support.
Importantly, there were positive impacts for the active members that joined in the discussions as well as the young people who simply read the comments of others, demonstrating that peer support is effective even for those that don’t actively contribute, but get value from hearing the experiences and stories of others.
ReachOut NextStep NextStep tool appearance ReachOut NextStep, launched in 2016, was developed as part of a project led by ReachOut in partnership with the University of Melbourne and the Young and Well Cooperative Research Centre.

The aim of project was to develop and evaluate a service model to facilitate help-seeking by providing a gateway to relevant and personalised mental health information, resources and services.
ReachOut NextStep, designed for and with young people, is now an important feature of the ReachOut service (ReachOut.com) and in providing a referral pathway when additional support is required, beyond self-help.
The NextStep tool is the outcome of a co-design and development process21 with the aim of: relieving distress / increasing positive affect simplifying the help-seeking process    decreasing barriers to access 21 Blake V., Buhagiar K., Kauer S., Sanci L., Nicholas M., and Grey J., 2016, Using participatory design to engage young people in the development of a new online tool to increase help-seeking [online], Journal of Applied Youth Studies, Vol.

1, No.

3, 2016: 68-83.


8 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health   increasing journey satisfaction and service awareness increasing intentions to seek help (and service use).
NextStep is accessible anytime and from any device and for young people: validates their feelings and shows them they are not alone  provides them with a place to start and show them what’s next  walks them through the process   provides them with a sense of hope  tunes into their changing needs  makes it easy to act and connect to support.

I’ve felt a lot better and stronger about my decisions since using ReachOut.

It has made getting help less scary.


Female, 16 As part of developing NextStep ReachOut drew on the expertise of 10 leading mental health service providers.

More than 600 young Australians participated in the project through help-seeking workshops; concept testing; prototype and user experience testing; the randomised control trial; functionality workshops; content and multimedia workshops; and ongoing through a youth advisory group.
The NextStep randomised control trial (RCT), conducted with the University of Melbourne, demonstrated it was a more satisfactory approach to help-seeking (compared to usual help-seeking strategies), reduced negative affect and improved quality of life up to three months after using the tool (as measured by the Assessment of Quality of Life instruments).
A further independent study of ReachOut NextStep by Deakin University has shown that the tool is cost-effective in terms of reducing costs associated with professional healthcare consultations.

This was attributed to matching young people to the best support for them based on their needs.
NextStep today references 90 symptoms, 12 issues, five severity levels for each issue, 25 apps and tools, 5 online forums, 14 chat services, 41 phone services, 28 face-to-face services, 29 practical tips, 250+ articles and stories, 12 videos, 60 pathways and thousands of possible combinations.

Around 4,200 young people use the NextStep tool on the ReachOut.com platform each month.
Next Step has been developed as a ‘widget’ and can be made available on sites external to ReachOut, for example, service providers, universities and schools.

Innovation agenda ReachOut has developed a framework to identify, analyse, prioritise and develop new functionality and products as part of an innovation agenda.
The focus of current work is to use technology, service data and cross-sector collaboration to:  deliver a more personalised service that matches ReachOut’s self-help resources, apps and tools to individual user circumstances, including identifying users at increased risk collaborate with youth mental health services to integrate service options from psychoeducation and peer support through to clinical support and treatment, and so that young people have a more joined up and effective experience reduce duplication and cost inefficiency across the mental health system of care.
  The primary aims of the innovation agenda are to increase access to digital peer support to add capacity to the mental health system and to leverage ReachOut’s core capabilities in co-design, digital mental health product development and online communications to better match our 2.4 million users to the right support at the right time.
9 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health ReachOut Schools Given the early age of onset of many mental health disorders and the recognised need to build protective factors to both prevent and intervene early before mental health issues become problematic, a focus on mental health in schools is paramount.
Most young people are involved with schools and spend a lot of time there during their formative years.

For this reason schools are often the first place where mental health concerns are detected, yet educators often feel ill-equipped or too time-poor to respond appropriately.
ReachOut’s research has shown that educators are overwhelmed by an explosion of new and existing mental health initiatives targeted at schools, ranging from meditation and mindfulness apps, peer and lived experience speakers and other wellbeing and mental health promotion programs.

They are seeking simple, flexible resources that align with the curriculum and clearly fit within other mandated mental health and wellbeing strategies.
ReachOut Schools, funded through corporate and private philanthropy, is designed to respond to this need and provide high school educators with resources and tools to educate students about mental health, wellbeing and resilience, as well as build safe and supportive learning environments.

It also links educators with support services that can help them to better support students experiencing mental health difficulties.
1,698 schools and 19,809 educators are subscribed to the ReachOut Schools program, ultimately benefiting 495,225 students.

Gaps in current programs and supports News headlines talk of a mental health system in crisis, long waitlists for services and increasing demand on hospital emergency departments.
While there are significant gaps in programs and supports, the bigger issue is the capacity of our current mental health system to meet escalating demand – an issue explored in the 2014 ReachOut and EY report, Crossroads.22 It’s not just about gaps, the mental health system is at capacity and unable to meet escalating demand.

Scaling up face-to-face services to meet demand would require significant additional funding and capital investment, and 6 to 15 years to grow the workforce.
Is this model sustainable given increasing demand for effective treatments and rapid growth in government expenditure on health?

For young Australians, more than 70 per cent of young people who who require help and support do not get it, and at least one third of young people have had an episode of mental illness by the time they are 25 years old.
2.1 million Australians – 13 per cent of all adults in any given year – are struggling with mental health issues and want help, but find it inaccessible, while more than a quarter of those who did access services felt it did not meet their needs.23 The impact on Australia’s mental health system is already significant.
The help-seeking pathway for people experiencing depression, anxiety and other common mental health problems is to usually to go first to their GP, and then via referral to a mental health professional such as a psychiatrist or clinical psychologist.

In 2013 this meant a combined workforce of 36,300 GPs, psychiatrists and psychologists provided 14.3 million mental health related services.
22 Hosie A., Vogl G., Hoddinott J., Carden J., and Comeau Y., 2013, Crossroads: Rethinking the Australian Mental Health System, Sydney: EY and ReachOut Australia.

23 Australian Bureau of Statistics, 2008, National Survey of Mental Health and Wellbeing: Summary of results, 2007, Cat no 4326.0.
10 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health The modelling on which the Crossroads report was based showed that in the absence of any systemic changes, forecast population growth combined with an increase in the proportion of people seeking help from 6% to 12% of the total population (a target in the Fourth National Mental Health Plan and the National Mental Health Commission 2012 and 2013 Report Cards24,25) would lead to a further increase in demand for, and use of, services of between 135 per cent and 160 per cent over the next fifteen years across GPs, psychiatrists and psychologists.
This increase presents substantial challenges to the overall capacity of the mental health services workforce.

Taking into account the maximum number of services that can be provided by a single professional in a year, an additional 8,800 health professionals would be required – 4,500 GPs, 2150 psychiatrists and 2,150 clinical psychologists – over the next fifteen years in order to meet the projected demand.
Both psychiatrists and GPs typically require around nine years of training in order to qualify at a basic level, while for clinical psychologists the typical minimum period of training and development is six years.

Given these long lead times, an effective and wide-spread strategy to grow the number of mental health professionals would need to be implemented as a priority in order to meet predicted demand.
While the model examined only three key professions it is clear that other mental health professions such as mental health nurses are likely to experience similar issues and workforce shortfalls.

Further, resourcing this workforce growth would cost the Health budget (and taxpayers) $1.75 billion per year in 2027 in increased salaries for these three professions alone, and cumulatively add $9 billion (in today’s dollars) to the Australian health spend over 15 years.
These costs increase when you consider the substantial capital investment necessary in education and medical infrastructure to support delivery.
In summary these modest and conservative projections by ReachOut and EY show that to build and scale a face-to-face service delivery system to meet this anticipated demand would require:  significant additional funding investment, including capital investment in education and medical infrastructure to support delivery  between 6 and 15 years to train and grow the workforce.
There are serious questions to consider about the ability of our current system to deliver mental health services to meet the growing demand for accessible and effective treatments and that is sustainable, considering the rapid growth in government expenditure on health over the last decade.
Effectiveness of alternative programs and supports Previous findings and recommendations The need to improve mental health is a significant challenge facing every country, and many people receive little or no effective treatment or support.

There is a growing understanding that policy responses and services must address the needs of the population as a whole, groups at risk and people suffering from a wide range of mental health problems.

Improving mental health is a challenge facing every country.
There is a need to shift the focus from treatment and crisis, to early intervention, prevention and recovery.

The next generation of digital mental health services is required that is integrated across services and sectors.

24 National Mental Health Commission, A Contributing Life: the 2012 National Report Card on Mental Health and Suicide Prevention.

25 National Mental Health Commission, A Contributing Life: the 2013 National Report Card on Mental Health and Suicide Prevention.
11 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health The 2014 National Mental Health Commission report Contributing lives, thriving communities: Review of Mental Health Services and Programmes26 noted that Australian Government investment in mental health is currently reactive and tipped towards acute mental illness and people experiencing crisis.
This focus on people already in need, and already experiencing the social and economic impacts of mental ill-health, is inefficient.

It also noted that while the Department of Health was presumed to be the major funder of mental health supports, in fact the major funder is the Department of Social Services in providing income support for people who are living with the consequences of deteriorating mental health and psychosocial disability.
Model 1: Shift in resources, extracted from National Mental Health Commission, Review of Mental Health Services and Programmes, 2014 The National Mental Health Commission argued there was a need for a change in mental health service provision in Australia to shift groups of people towards upstream services (such as population health, prevention, early intervention, recovery and participation) to reduce pressure on downstream and more costly services (such as emergency department presentations, acute admissions, avoidable readmissions and income support payments), see Model 1.
This shift included access to innovative service delivery models such as digital self help.

The National Mental Health Commission review also concluded there was a need for the next generation of digital mental health services, that moved away from the current system of stand-alone services with some areas of integration, to one that integrates across services and sectors.
It noted that telephone helplines are not integrated, do not have common standards and there are limited referral pathways; that there was potential for users to be accessing the ‘wrong door’ (ie seeking to enter the mental health system through the wrong service option, and with no clear referral pathway); and duplication in information websites, gateway websites, crisis and telephone support, and gaps in peer and family support and therapist guided care.27 An example of the range of digital mental health services available for young people is provided in Table 2 below.
26 National Mental Health Commission, 2014, Contributing lives, thriving communities: Review of Mental Health Services and Programmes.

27 National Mental Health Commission, 2014, Contributing lives, thriving communities: Review of mental health services and programmes.
12 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Table 2: Youth digital mental health service landscape Self-help and peer support Apps and tools Online self-guided courses Telephone and webchat counselling Crisis support Source: HeadtoHealth available at www.headtohealth.gov.au and E-mental Health in Practice available at http://www.emhprac.org.au.
Note: indication of the type and range of digital mental health services, not a complete list.
More recently, in 2017 the Fifth National Mental Health and Suicide Prevention Plan28 included a commitment for governments to develop a National Digital Mental Health Framework in collaboration with the National Digital Health Agency, citing there was an opportunity to achieve a more cohesive and user-friendly approach to digital mental health services that can be supported as a legitimate component of a stepped care model.
As background to the commitment the Plan stated that:   transitions to digital mental health platforms were not occurring in a structured way telephone helplines proliferate and new internet models are funded by different commissioning agencies without visibility of what is being funded elsewhere 28 COAG Health Council, 2017, National Mental Health Strategy: The Fifth National Mental Health and Suicide Prevention Plan.
13 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health  there was an urgent need for an integrated approach to this activity that prevents duplication and unnecessary spending on product development.
– Recommendation 1: re-examine the advice of the National Mental Health Commission in its report Contributing lives, thriving communities: Review of Mental Health Services and Programmes including: to shift funding priorities from treatment and crisis, to early intervention, prevention and recovery, supported by innovative service delivery models that integrate digital self-help to develop the next generation of digital mental health services, that moves away from a system of stand-alone services, to one that integrates across services and sectors.
– Recommendation 2: as committed in the Fifth National Mental Health and Suicide Prevention Plan, develop a National Digital Mental Health Framework that will guide investment in and funding of digital mental health services and programmes, reduce duplication, and support digital mental health services to be used as a legitimate component of a stepped care model.

What do young people want from a mental health service?
Young people face considerable barriers to accessing support for mental health issues, whether practical such as lack of time or money, transport issues and lack of local services; or attitudinal such as embarrassment, fear of what could happen, desire for autonomy and a preference for self reliance.
A key way to make inroads into minimising the impact of these barriers is to design services that young people want, that embody the characteristics that are important to them, and that are accessible and meet their needs.

Young people want services that are:   face-to-face followed by online confidential, accessible, friendly, helpful and credible information in a range of formats eg brochures, games, videos, online chat   not explicitly a mental health service.
In 2018, Mission Australia and ReachOut brought together qualitative and quantitative data on the experiences of young people living in rural and regional Australia.

As part of this, young people were asked about the aspects and characteristics of services that influence their decisions about whether or not to seek help, and what characteristics would foster their engagement with services.
While the research focused on rural and regional young people, there are broader applications, including for young people located in metropolitan areas.

14 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Types of services young people would access Young people were asked about their preferences in terms of the types of services they would access.
In particular, they were asked to imagine that they were experiencing exam stress or bullying, or were drinking too much, and that they needed to seek help or support from a service.

They were then asked what type of service they would access, with four possible response options: a face-to-face service; a telephone service; an online service; or none of these.

The most popular types of services nominated were face-to- face (53.4 per cent) and online (44.3 per cent) services.
20.8 per cent nominated a phone-based service and 12.9 per cent of young people indicated that they would seek help from none of these.

Almost one in five males (18.0 per cent) indicated they wouldn’t access any of the services listed, which was twice the proportion of females (9.3 per cent).

A higher proportion of young people in inner regional areas indicated that they would access a face-to-face service (55.9 per cent) compared to outer regional, remote and very remote (ORRVR, 48.7 per cent).
Respondents could nominate more than one type of service.

Accessing an online service was the second-highest preference in both inner regional (44.7 per cent) and ORRVR (43.4 per cent) areas.

Characteristics young people look for when choosing a support service Young people were asked to think about support services that could help with a number of common issues that young people experience.

The issues included drinking too much, experiencing bullying, and stressing out about exams.
They were then asked an open-ended question about the five most important characteristics/features they would consider in choosing a service to get support for these issues.

The top five desirable support service characteristics were identified.
The top five desirable service characteristics nominated by young people were:  confidential (33.9 per cent)  accessible (27.8 per cent) friendly (25.3 per cent)   helpful (20.8 per cent)  credible (14.8 per cent) Service helpfulness (34.0 per cent) was cited by males as the most important characteristic they would consider when thinking about accessing a service, while females cited confidentiality as their most important characteristic (42.3 per cent).
Desirable service characteristics that encourage a young person to engage with a service Young people were asked to envisage their ideal support service, and to describe what it would offer and how it would make them feel.

Many participants described their ideal place as ‘homely’, ‘open’ and ‘welcoming’.

Often, young people described their ideal service as one that included features such as televisions, music, food, drinks, posters, lounges and beanbags.
They didn’t want the service to feel like a doctor’s waiting room, or to feel clinical or sterile.

It was important to young people that the service didn’t make them feel intimidated, overwhelmed, pressured or imposed upon; instead, it should allow the young person to feel in control of their help-seeking experience.
15 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Having a chill environment is necessary too!

Nothing too clinical!

Going into a more relaxed environment should comfort the young person.

— Female, 20, NSW A service staffed by approachable people who genuinely cared about young people was central to the vision of the ideal service.
All staff in the service, from the receptionist to the mental health professionals, needed to be empathetic; someone that they felt they could talk to, and who would listen to them without judgement.

Employing younger people who were similar in age was also seen as important, as young people felt these people would be more approachable and relatable.

...

I can walk in and see people that are willing to help and listen, those who won’t criticise my situation.
— Male, 20, WA People to talk to, but also someone who can just listen to me.

— Female, 17, QLD An ideal service should provide information about mental health in a range of formats – for example, brochures, games and videos.

Research participants discussed online service components, most commonly apps or online chat.

They described the appeal of these features as being the anonymity they afforded and the accessibility of services that are available 24/7 from virtually any location.
Online platforms were also valued, as they allowed for self-guided help-seeking, thus placing the young person firmly in control of their help-seeking experience.

Honestly the ideal support service is online.

Young people are so used to having everything at their fingertips … Being virtual, I think the person has more control.

— Female, 20, NSW It would be great to have a place that offers help through apps and online on a variety of topics.
Having a social media presence is almost vital these days – it’s where people connect.

— Female, 17, QLD Recommendation 3: ensure a range of different types of services are available for young people and that meet their service needs and preferences, and to help overcome barriers to help-seeking.

What digital technologies offer?


Digital technologies offer a variety of evidence-based, scalable, cost-effective programs and can be provided as an alternative in areas where there is little access to face-to-face services.29 Technology offers service providers an opportunity to reach young people with mental health issues in their natural digital environment.

Digital technologies are an opportunity to reach young people in their natural digital environment.
They address practical and attitudinal barriers to accessing traditional face-to-face services.

For young people, the digital world is not something new, but something that is an extension of who they are.

Young people are looking to engage in mental health support in this digital world, in a way that makes sense to them.
In Australia, 88 per cent of teenagers go online more than once a day; 86 per cent have home broadband; and 80 per cent use a smartphone.30 To be effective digital services must be engaging to young people and integrated with face-to-face youth mental health services.

29 Mission Australia, in association with Black Dog Institute, 2015, Young People’s Mental Health over the Years: Youth Survey 2014.

30 Australian Communications and Media Authority, 2016, Research Snapshot: Aussie kids and teens online.
16 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Further, Australians are increasingly dependent on the internet to obtain information and interact with services, due to flexibility, convenience, choice, cost and time savings.
Young people are leading this trend, with a large body of research showing that young people go online to seek health information,31 and in fact prefer this medium for accessing information, advice or support.32 Digital mental health services are playing a progressively larger role in the delivery of services and in supporting young people.
This role includes information, prevention, assessment, diagnosis, counselling and treatment programs focused on a range of conditions and severity levels.33 Self-help provides a very viable mental health support option, and online self-help provides the opportunity to support large numbers of people effectively at an early stage, or as a cost-effective adjunct to formal care options.

In recent years, more digital self-help options have become available.
Examples include a number of online self help programs for anxiety and depression, such as myCompass (building resilience and wellbeing), This Way Up (coping with social anxiety) and Mood Gym (preventing and coping with depression).

Mental health mobile apps can be used on their own or as an adjunct to face-to-face treatment for mild to moderate mental health disorders.
While more research is needed, a systematic review of mobile apps for mental health shows that apps have the potential to be effective in reducing depression, anxiety and stress.34 Given the wide use of smartphones and apps, online self-help may significantly increase access to treatment.35 We know that young people face a number of attitudinal and practical barriers to accessing traditional mental health-care services.
Online self-help provides an important way to potentially overcome the barriers faced by young people36 including greater consumer empowerment, anonymity, 24/7 availability, greater accessibility (especially in rural, regional and remote locations), and reduced costs for both consumers and service providers/funders.
Ensuring that digital mental health services are evidence-based and effective is an important first step, however to encourage extensive uptake of these interventions young people need to find them engaging (to avoid high drop-out rates) and they must be integrated with face-to-face youth mental health services.
Barriers to seeking help, extracted from ReachOut and EY Report, One Click Away, 2016 Face-to-face 31 Gould M.S., Munfakh J.L., Lubell K., Kleiman M. and Parker S.,Seeking help from the internet during adolescence, 2002, Journal of the American Academy of Child and Adolescent Psychiatry, 41(10):1182-9.

32 Ivancic L., Perrens B., Fildes J., Perry Y. and Christensen H., 2014, Youth Mental Health Report, June 2014, Mission Australia and Black Dog Institute.
33 Mission Australia, in association with Black Dog Institute, 2015, Young People’s Mental Health over the Years: Youth Survey 2014.

34 Donker T., Petrie K., Proudfoot J., Clarke J., Birch M.R.

and Christensen H., 2013, Smartphones for smarter delivery of mental health programs: A systematic review, Journal of Medical Internet Research, 15(11):e247.

35 Ibid.
35 Ibid.

36 Farrand P., Perry J., Lee C. and Parker M., 2006, “Adolescents’ preference towards self-help: Implications for service development”, Primary Care and Community Psychiatry, 11(2):73–79.
17 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Recommendation 4: trial the integration of youth-focused digital mental health tools and services with face-to-face youth mental health services.
Adding capacity to the mental health system and prevention through digital technologies There is a strong case for increased investment in digital technologies to improve the mental health and wellbeing of individuals and to reduce the broader social and economic costs associated with mental ill-health.
In the short term this investment should focus on intervening early, increasing access and adding capacity to the mental health system so that more people get help; and in the long term, developing a framework and undertaking reforms that build a new, scalable, effective and integrated 21st century mental health care model.

Short-term: increased investment in digital technologies to increase access and add capacity to the mental health system.
Long-term: build a new, scalable, effective and integrated 21st century mental health care model.. Digital technologies are used to expand prevention programs to further reduce the social and economic costs of mental health.

The ReachOut and EY report A Way Forward37 noted that mental health system reform is complex and will take significant time, commitment and effort.
It made the case for increased investment now in scalable, online interventions as the ‘first line of defence’ to:  boost the overall capacity of the mental health system, so that more people get help  deliver additional capacity at least five years sooner than it would take to build capacity in the health workforce that is less costly to deliver.
 As outlined above, there are a range of practical and attitudinal barriers, as well as capacity constraints, which means there continues to be significant unmet need for mental health services in the community.

Online services address many of the barriers to accessing services and have the potential to boost the overall capacity of the mental health system, particularly in the short term.
Research has also shown that a range of online interventions are effective, particularly for those experiencing symptoms of depression and anxiety.

These interventions currently exist and could immediately help address unmet demand, if there was coordinated effort to promote them to users and health professionals.
This approach is in contrast to building and scaling the face-to-face system which would take significant funding and 6 to 15 years to grow the workforce (see section, Gaps in Current Programs and Supports).

The projections produced for A Way Forward, put the cost of scaling up an existing, online intervention at $9.70 per person once 10,000 or more people used the service each year (or $97,000 per year).
In comparison, the cost associated with accessing face-to-face support varied from $507 to $875 per person, depending on the number of sessions.

The total Medicare costs to enable 10,000 new people to obtain treatment could reach as much as $8.45 million per year.

37 Hosie A., Vogl G., Carden J., Hoddinott J. and Lim S., 2015, A Way Forward: Equipping Australia’s Mental Health System for the Next Generation, Sydney: EY and ReachOut Australia.
18 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health A Way Forward also considered that reducing the prevalence of mental disorders was a priority, and to further reduce the economic costs of mental health.

The two ways of doing this are by treating existing cases and preventing new cases.
A range of studies have found that, even under ideal conditions, only half of the burden of all mental health disorders could be averted with treatment (both psychological and pharmaceutical)38.

Australian research estimates that existing treatment averts only 13–16% of the disease burden from mental health disorders and even if all cases of depression were treated using evidence-based treatments, only 24–52 per cent of the total disease burden would be averted39.
On this basis, the prevention of mental disorders in the first instance is critical to reducing the overall burden of mental illness and associated costs while simultaneously reducing demand on downstream clinical care systems.

The evidence regarding prevention and early intervention programs is robust, with agreement across systematic reviews and meta-analytic studies regarding the effectiveness of selected and indicated (targeted) prevention programs in reducing the incidence of depression and anxiety.
In particular, there is strong evidence for preventive interventions that combine screening adolescents for early signs of depression and the subsequent provision of brief cognitive behaviour therapy to those identified as being at high risk40.

Such initiatives have been shown to reduce the incidence of depression in adolescents by 35 per cent41.

Despite evidence demonstrating the effectiveness of prevention programs, there remains significant potential for investment and expansion.
One potential explanation for the current lack of investment is the focus on treating existing conditions, not prevention, and as noted in this submission the bulk of funding is directed towards face-to-face services, acute care and income support payments.

Using digital technologies to deliver prevention interventions has significant potential, particularly in removing the need for health or education professionals to administer the programs, and for delivery at high scale.
Recommendation 5: in the short term increase investment in digital technologies to increase access and add capacity to the mental health system, and expand prevention programs.

Recommendation 6: in the long term develop and build a new, scalable, effective and integrated 21st century mental health care model.

38 Cujipers P., Van Straten A. and Smit F., 2005, Preventing the incidence of new cases of mental disorders: A meta-analytic review, Journal of Nervous and Mental Disease, 193:2.
39 Mihalopoulos C., Vos T., Pirkis J and Carter R., 2012, The population cost-effectiveness of interventions designed to prevent childhood depression, Pediatrics, 129:1-8.

Doi: 10.1542/peds.2011-1823.

40 Merry S.N., Hetrick S.E., Cox G.R., Brudevold-Iversen T., Bir J.J. and McDowell H., 2012, Cochrane Review: Psychological and education interventions for preventing depression in children and adolescents, Evidence-based Child Health: A Cochrane Review Journal, 7(5): 1409-1685.
41 Mihalopoulos C., Vos T., Pirkis J and Carter R., 2012, “The population cost-effectiveness of interventions designed to prevent childhood depression”, Pediatrics, 129:1-8.

Doi: 10.1542/peds.2011-1823.


19 Mental Health and Suicide PreventionSubmission 168 - Attachment 3 ReachOut Submission: Productivity Commission Inquiry, The Social and Economic Benefits of Improving Mental Health Conclusion Nearly half of all Australians will experience a mental health problem over the course of their lives, and the costs are significant for both individuals and the broader community.
ReachOut is an online mental health service for young people that uses evidence-based, digital technologies to provide immediate support that is low cost and high scale, at ReachOut.com and through other channels, such as, social media.

ReachOut collaborates with academic and service partners to develop, build and improve the service model, and works with young people to ensure their views, needs and insights inform service design and delivery.

Improving mental health is a challenge facing every country.
The escalating demand for mental health care and associated costs, means our mental health system is at capacity.

Scaling up face-to-face services to meet demand would require significant time and funding.

Recent reviews have talked about the need to shift the focus from treatment and crisis, to early intervention, prevention and recovery, supported by new service delivery models that integrate digital mental health.
Young people have told us that their preference is for services that are face-to-face followed by online, that are confidential and accessible, and that don’t feel like a clinical (doctor’s waiting room) service.

Digital technologies are an opportunity to reach young people in their natural digital environment, and address practical and attitudinal barriers to accessing traditional face-to-face services.
To be effective, digital services must be engaging (to avoid high drop-out rates) and integrated with face-to-face youth mental health services.

Digital technologies can immediately boost the capacity of the mental health system and through long term reform deliver a new, scalable and effective 21st century mental health care model that integrates with face- to-face services, expands access to prevention and treatment programs, addresses social and economic impacts, and importantly prevents suicide.
Contact Mr Ashley de Silva Chief Executive Officer ReachOut Australia Level 2, 35 Saunders Street PYRMONT NSW 2009 Telephone: 02 8029 7777 20 Mental Health and Suicide PreventionSubmission 168 - Attachment 3