In the second part of her series, Dr Louise Stone explores whether digital mental health services provide the security and value for money we expect.
In it Previous article, I explored current policy positions on the use of digital mental health services and discussed how these services are being actively promoted and incentivized to drive greater participation. In this article, I will explore the cost, accessibility, and safety of these interventions. With another $588 million invested in the sector in the recent federal budget, it is time to take a closer look at the cost-benefit equation. After all, this investment is equivalent to 2,350 full-time GPs carrying out long consultations.
Are digital mental health services cheap?
Digital services are marketed as a cost-effective solution to our growing mental health crisis. However, they may not provide the value for money we expect. It is almost impossible to get a complete picture of public financing of digital health services because there are many funding avenues and data sources. Some services are funded directly by governments through core funding (e.g. Life line). Some are financed through commissioned services by the different primary health care networks. There are also federal research grants to develop and evaluate programs through the National Health and Medical Research Council and Fund for the Future of Medical Research, and specific grants that are not challenged (for example, the development of the Brain and Mind Center of Innowell). There are additional commercial benefits for some services, with profits for shareholders and occasionally contributions or sales from consumers.
For example, Head space received $23.5 million in core funding from the federal government in 2023, some of which will be directed toward digital mental health initiatives. Primary Health Networks have also been funded to provide mental health services to youthwhich requires headspace commissioningin 134 million dollars in 2023. Headspace also attracts philanthropic funding and state government funding. How much of this funding is spent on digital health interventions is unclear.
However, even if we look at federal funding alone, digital mental health services are not cheap. The following table has been prepared using publicly available material, specifically Grant Connectiongovernment records of federal grants awarded and the period 2023-24 federal budget documents. This is a significant underestimate of funding because there are three major sources of funding that are not included. The first is grants through philanthropy, industry, and other government support (e.g., grants from state governments). The second is basic financing. The third is commercialand sales of applications and their related data provide important benefits to the companies that design them.
GP costs to the federal government are calculated using Medicare statistics for mental health item numbers.
Even restricting digital health funding to federal sources, each person who uses digital health services costs the taxpayer $76 in federal funds, while each person who uses a primary care physician for their mental health costs the taxpayer $81.
With a funding difference of less than five dollars between a digital health service and a GP service, digital mental health is not cheap.
| Category and organization | Financing (millions) | People viewed (millions) | federal investment |
| Federal Budget Announcement Continued Digital Mental Health Funding 2023-24 | $44 | – | – |
| Federal research grants focused on digital mental health 2023 | $27.3 | – | – |
| Selected Federally Funded Programs (Black Dog Institute, StandBy Support After Suicide, eClinic and InsideOut Institute’s Digital GP Hub, Head to Health website) 2023-24 | $25.9 | – | – |
| Full new investment in e-mental health by the federal government in 2023 | $97.2 | 1,248 (4.8% population) | $78 per person using a digital health service |
| General practice mental health. | $269 | 3,224 (12.4% population) | $83 per person using a primary care doctor |
Are digital mental health services safe?
At a minimum, we need assurances that digital mental health interventions are safe. It is the developers’ responsibility to demonstrate that there is a solid research basis for their efficacy claims. There should also be transparent damage reporting.
One of the biggest concerns is data security and privacy, and this is where I have problems with the term “consumer.” Although many people can act as informed consumers when they are unwell, the term “consumer” implies that they are well enough to make informed decisions about therapeutic products. Some consumers are patients who may lack normal energy and cognitive ability when they are unwell. They have the additional protection of regulation by the Therapeutic Goods Administration (TGA) when we prescribe a medication or device. This gives patients some confidence that the medication or intervention they are prescribed is safe. Of course, patients still need support to consider their options, whether through conversations with doctors or open and transparent communication of risks and benefits with publicly available educational materials.
With digital products, transparency is essential, because patients have the right to informed consent. Consumers must be clearly informed about how their data will be used. collected, managed and used, because data management is critical to preserving your trust in your referring physicians. There is evidence that service users may have limited knowledge and awareness privacy, confidentiality and security. They may have the right to decide how risk averse they choose to be regarding digital mental health tools, but developers may not make these risks clear. Many applications do not show associated risks. Some digital tools passively monitor and collect data, and many forward it to commercial entities. Emerging applications that use sensor tracking and machine learning can provide personalized feedback about mental health, but also capture granular data about a person’s health, a significant privacy risk.
Digital designers must be responsible for the accuracy of their content. Some content in the app is inaccurate or even harmful. Few digital mental health services consider diversity. Artificial intelligence (AI) is known for its bias towards more privileged populations and one author claims that the acronym stands for “Increased inequality.”
In response to these concerns, there have been attempts to regulate digital health productswith the TGA producing a regulatory guideline. The guideline suggests that any service that is “based on established clinical practice guidelines referenced and displayed in the software” is exempt from the requirement to register. The decision tree for digital devices is found. here. Based on this decision tree, it seems likely that most currently available digital mental health services will be exempt.
The blurring of the lines between information and therapy is a cause for concern. There is ample evidence in favor of online education in all disciplines. Open and accessible information that takes a consumer-centric approach and is co-designed with consumers and caregivers is clearly empowering and effective.
However, digital mental health tools that claim to be therapeutic are a different matter. Therapeutic products should be held to higher standards than non-specific “wellness” apps or information sites, and should be required to comply responsibility and transparency standards. There is an even greater need for regulation when these products use or are developed with AI.
There will always be a market for unregulated applications. We have seen this in the fitness industry. However, if GPs want to give credibility to digital tools by recommending them to patients, they must be confident that these tools are credible. This requires stricter regulation.
Dr Louise Stone is a GP in Canberra with clinical, research, teaching and policy experience in mental health. She is an associate professor in the social foundations of medicine group at the Australian National University School of Medicine.
Read part 1 of their series on digital mental health services. here.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, the MJA either Insight+ unless so indicated.
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