Introduction

Mental disorders are a prevalent global issue, with approximately one in eight people experiencing a diagnosis (World Health Organization, 2019). These disorders can cause significant distress and impact relationships and communities. Evidence-based interventions exist, but very few people have access to these, particularly those living in rural and remote areas, elderly and ethnic minorities (Patel et al., 2007). Barriers to access include the lack of perceived need for care, lack of early identification, lack of awareness of the availability and effectiveness of existing interventions, limited availability of specialist clinicians, and affordability (Corscadden et al., 2019; Patel et al., 2007). Digital mental health interventions offer a promising solution to these barriers. Digital mental health interventions are online, structured, evidenced-based therapy programs that are either self-guided or clinician-supported (Lattie et al., 2022). Digital mental health interventions are low cost, can help improve access to mental health care, and can be accessed anywhere (Hollis et al., 2015).

More importantly, there is strong evidence supporting the effectiveness of digital mental health services for a range of mental health conditions. For instance, Karyotaki et al. (2018) conducted a systematic review that evaluated the effectiveness of supported digital mental health interventions for depression in adults. The review pooled data from 4889 adults with depression from 24 randomised controlled trials. Most interventions were based on Cognitive Behavioural Therapy. The review showed significantly higher response rates in the digital intervention than the control condition (56.2% vs 35.1%), with the odds of response more than double in participants who received the intervention (OR = 2.49).

Similarly, significant effects of supported digital mental health services have been found for generalised anxiety disorder (GAD), social anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder in adults. For example, Eilert et al. (2021) reviewed the evidence for digital mental health services for adults with GAD incorporating data from 20 RCTs with 1,333 participants. They observed a large reduction in anxiety symptoms (g = 0.79) and worry (g = 0.75) with sustained impacts post-intervention (g = 0.84).

Additionally, Guo et al. (2021) conducted a systematic review that included adults with social anxiety disorder, pooling data from 20 RCTs with 1743 adults. They found that digital mental health services showed a large reduction in social anxiety symptoms compared to waitlist controls (g = 0.79). Likewise, Polak et al. (2021), who reviewed the impacts of digital mental health services for adults with panic disorder (with or without agoraphobia) encompassing 13 RCTs and 1214 adults, also observed a large reduction in panic symptoms post-intervention.

In terms of acceptability, an umbrella review covering 151 unique studies of digital mental health services indicated that guided and unguided digital mental health services were acceptable to adult users with depression and anxiety disorders (Treanor et al., 2021). Users are highly satisfied and would recommend services. Lastly, studies that examined health professionals’ satisfaction with guided digital mental health services also found it to be high (Simon et al., 2019).

Despite the effectiveness and acceptability of digital mental health services, researchers have identified a number of barriers at the consumer and health professional and organisational level. Barriers at the consumer level include a lack of awareness of these intervention, low computer competency, and concerns about data privacy, safety and confidentiality (Ebert et al., 2019; Batterham et al., 2019). Barriers for health professionals include lack of familiarity and awareness, lack of confidence and skills, perceptions that consumers have poor internet or out-of-date devices, lack of time and motivation to learn new ways of delivering services, concerns about workflow disruption and additional workload, and worries about risk management, confidentiality and data security; and perceived loss of therapeutic relationship (Davies et al., 2020; Ganapathy et al., 2021). At the organisational level, concerns about funding may impede utilisation (Ganapathy et al., 2021). The Australian Government funds numerous digital mental health services, which provide a range of interventions, including promotion and prevention, assessment, referral, treatment and recovery. The three most prominent services are Mental Health Online, MindSpot and THIS WAY UP. These services, although funded by the Australian Government, were developed in partnership with mental health experts, consumers, public health services, and universities. These services have been operating for over 10 years, are free to consumers, and have a strong track record of usage. They offer web-based information, online assessments including risk management, and self-directed and therapist-supported treatment, mainly for people with depression and anxiety disorders. The number of users accessing and providers delivering care through them is steadily increasing (Mahoney et al., 2021; Titov et al., 2020).The Australian Productivity Commission Mental Health Inquiry Report recognised the potential benefits of these services and recommended that the Australian Government fosters and expands their reach (Australian Productivity Commission, 2020). However, the use of these services by providers and consumers remains inconsistent, and they are not fully integrated into mental health care and the broader mental health landscape (Bassilios et al., 2022a). To overcome some of these barriers and harness the opportunities and acceptance of digital mental health services, we sought to understand the consumers’ experiences with accessing services through Mental Health Online, MindSpot, and THIS WAY UP, which include the option of clinician support. Gaining a consumer perspective can help to understand the factors that optimise or hinder effectiveness of these services, identify any challenges users face, identify areas of improvement, validate and build trust in the services and ensure that the services meet the needs of the people they are intended to serve. Furthermore, this consumer perspective can help understand how these digital mental health services can be sustainable to bridge mental health care gaps in Australia and enable optimal outcomes for consumers using these interventions.

Method

Design, Setting and Recruitment

We conducted an online survey of consumers who had used digital mental health services. The digital mental health services acted as intermediaries for the recruitment of consumers. They emailed an invitation to complete the survey to > 3000 consumers (130 Mental Health Online, 447 MindSpot, 2600 THIS WAY UP) between 20 and 24 January 2022. MindSpot also advertised the survey via social media on 20 January, and Mental Health Online placed the survey on its website landing page where users login (from 21 January to 23 February). Surveys for MindSpot and THIS WAY UP were open until the 25 January, and the Mental Health Online survey closed on 15 February 2022. At the end of the survey, consumers had the opportunity to register their interest in taking part in an interview to provide more in-depth information.

Consumers who completed the survey received a $20 e-voucher to compensate them for their time. Consumers who also participated in the interview were provided with an additional $30 e-voucher to compensate them for their time.

The study was approved by the Human Research Ethics Committee at the University of Melbourne (ID: 22376).

Survey and Interviews

We conducted a purpose-built brief online survey and telephone interviews to gain information about consumers’ experience receiving mental health care through digital mental health services (see Appendix 1). The survey and interview schedule consisted of both closed- and open-ended questions. Questions elicited information about consumers’ experiences of receiving care through the supported digital mental health services, the activities, modules and the therapist support they received, whether they thought that the service improved their access to care and/or the quality of care they received, their satisfaction with this care, and whether this care had any impact on outcomes for them. Survey data was collected via Qualtrics. Twenty-three interviews were conducted by 3 psychologists (AM conducted 13 interviews; SM conducted 7 interviews; and MF conducted 3 interviews). Interviews were recorded and transcribed.

Statistical Methods

Quantitative data were analysed using SPSS (Version 28). Data were described using percentages and frequencies and where appropriate means and standard deviations were calculated.

Qualitative data were entered into an excel spreadsheet and thematically analysed (Braun & Clarke, 2006). This involved reading through the text multiple times to identify patterns and codes and grouping them into themes that reflected each of the interview questions. Descriptive coding of responses and development of themes was conducted by one team member (AM, MF or SM). Ten percent of these descriptive codes were double coded by another member of the team (AM, MF or SM).

Results

Participants

Survey Respondents

A total of 351 consumers participated in the survey. Most of these consumers (63%) had used THIS WAY UP; 29%, MindSpot; and 9%, Mental Health Online. Table 1 describes their socio-demographic characteristics and internet access. Most consumers across digital mental health services were female (73%), under the age of 50 years (75%) and, except for Mental Health Online consumers, resided in New South Wales (NSW). Mental Health Online consumers most commonly lived in Victoria. This trend of users broadly represents the population distribution in Australia. Consumers primarily used the National Broadband Network (a national data network) to access the internet.

Table 1 DMHS consumer survey respondent characteristics and internet access, by service and overall
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Interview Participants

Twenty-three of the survey respondents also completed interviews—39% were users of MindSpot; 35%, THIS WAY UP; and 26%, Mental Health Online. The socio-demographic characteristics of interviewee consumers were largely similar to survey participants (Appendix 2). However, consumers who took part in the interviews were slightly older (with approximately 50% of consumers being over the age of 59 years) than those who took part in the surveys alone.

Consumer Use of Digital Mental Health Services

Survey Respondents

Survey data respondents (N = 351) were asked about their experiences of using the digital mental health service. Their responses are recorded in Table 2. Most Mental Health Online (78%) and MindSpot (39%) consumers found out about the digital mental health services via an online search, whereas most THIS WAY UP (72%) consumers found out about the service through their health care provider. More than half of the overall number of consumers (61%) indicated that digital services was their preferred method of accessing mental health care. Proportionally, more Mental Health Online (78%) than MindSpot (48%) and THIS WAY UP (47%) consumers had experienced previous barriers to seeking care. Consumers experienced a range of previous help-seeking barriers, most common amongst which were thinking symptoms would improve without intervention and/or were not sufficiently severe, the affordability of care and a preference to rely on oneself.

Table 2 Consumer use of DMHS, by service and overall
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Two-thirds of survey respondents (64%) were first-time users of a digital mental health service. A variety of reasons prompted consumers to access the digital mental health services. Most commonly, across services, consumers accessed care because they were struggling to cope, they felt they needed professional help, and they had noticed that their symptoms had worsened. A higher percentage of THIS WAY UP (58%) than Mental Health Online (0%) and MindSpot (19%) consumers had also sought help because a provider had recommended it.

Interviewees

Consumers who took part in an interview (n = 23) were also asked whether digital mental health services were their preferred method for accessing treatment and to describe the main reasons for accessing help. Sixty percent of consumers (n = 14) indicated that digital services were their preferred method for accessing mental health care. A small portion of consumers preferred face-to-face services or a combination of digital, face-to-face or phone services. One such consumer said:

I actually do think the combination is helpful. Like, I do think having some face to face where you’re physically with the person and building that relationship is very valuable.

Consumers reported a variety of reasons for accessing digital mental health services. One-third of consumer interviewees (n = 8) cited the accessibility and the option to access the service in their own time as their main reason for using the supported digital mental health services. These consumers made comments like:

I feel I understand my own circumstances, and the digital online program allowed me to access what I need quickly.

I got access to the modules quite quickly and I wanted to do something that was self-directed. I wanted to feel like I was taking charge of my own mental health recovery and I thought what the program offered was an ability for me to really be in control of it.

Other consumer interviewees reported that they accessed digital mental health services because it was recommended by a health provider (n = 5) or they had difficulties accessing other mental health services (n = 5) or because an online search led them to the digital mental health services (n = 5).

Consumer Experiences of Specific Aspects of Digital Mental Health Services

Survey respondents were asked about their experiences of specific aspects of the digital mental health services including assessment, modules, activities, and accessing support through a therapist. Those that took part in interviews were asked to elaborate on their experience of using the modules, activities, accessing therapist support and their overall satisfaction.

Assessments

As described in Table 3, approximately 90% of survey respondents across services completed an assessment. Most Mental Health Online (65%) and MindSpot (68%) consumers completed the assessment in between 10 and 30 min, and most THIS WAY UP (55%) consumers completed their assessment in under 10 min. Most consumers described their experience of completing an online assessment as positive. Approximately 80% of consumers across digital mental health services “strongly agreed” or “somewhat agreed” that the assessment was appropriate, relevant, accurate, and easy to read and understand and that it assisted them in understanding their situations.

Table 3 Consumer experience of DMHS assessment, by service and overall
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Self-Directed Modules

Survey Respondents

Similarly, approximately 97% of survey respondents across all three services completed online modules. Their responses are shown in Table 4. About 70% of both MindSpot and THIS WAY UP consumers completed modules in under 31 min, and 50% of Mental Health Online consumers took 31 min or longer to finish. Most consumers described their experience of using the modules as positive.

Table 4 Consumer experience of DMHS self-directed modules, by service and overall
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Interviewees

These beneficial outcomes were confirmed by consumers who took part in the interviews. Three-quarters (n = 18) of these consumers discussed the modules in a positive light. Fifty percent (n = 9) of these consumers indicated that the structure of the modules was good, with 46% of interviewees indicating that the modules were easy and “logical” to use and navigate. Forty-three percent (n = 10) also found the content of the modules to be informative, indicating the information was relevant, accessible, engaging and easy to understand. These consumers made comments such as:

So it was actually for me helpful because it was stuff that I’d never encountered and enabled me to evaluate my mental health and why I thought the way I thought and that type of stuff – so for me, it was all new stuff.

I like that they were broken up into sessions; the modules you could do every week were broken up and, then you could basically take it step by step.

On the other hand, 21% (n = 5) of consumers interviewed voiced that there was too much information in the modules. One such consumer commented:

It’s not really negative but is that there was a lot of content in some, like really, really packed full of different topics some of them.

Self-Directed Activities

Survey Respondents

In total, 87% (n = 307) consumers across all services completed digital mental health activities. Their responses are recorded in Table 5. Over 70% of consumers across services completed activities in under 31 min. Over 80% of consumers across digital mental health services “strongly agreed” or “somewhat agreed” that the activities were informative, relevant, easy to understand, engaging, made them think and taught them new strategies. Across all services, approximately 70% “strongly agreed” or “somewhat agreed” that the activities were visually appealing.

Table 5 Consumer experience of DMHS self-directed activities, by service and overall
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Interviewees

Consumers who took part in the interviews were also asked about their experience with the activities. Seventy-two percent (n = 17) of these consumers again discussed the activities in a positive light. Approximately 50% (n = 12) of consumers cited that the content was relevant and that they learnt new strategies and were able to apply the content and strategy to their situations. These consumers made comments like:

The practising and the reinforcing that these activities may give you to try over the week and so on – yeah, I found them very useful yeah – I can’t recall all of them but some of the ones that have stuck in my mind I still use today.

Even the other day, I was anxious about something, and I got out the worksheet and used it; it helped me. So, I don’t actually worry anymore like I used to. So, it’s just showing that that practical format and the templates, so I think it’s the actual templates that you can refer back to and keep.

Other positive elements of the activities included that they were easy to understand, informative and caused consumers to reflect and think about their situation. However, a small percentage (17%) of interview participants did not complete the activities and reported that the activities were not at all relevant to their situation.

Therapist Support Services

Survey Respondents

In total, one-third (n = 117) of all consumers had accessed a therapist as part of their digital mental health service experience. Their responses are recorded in Table 6. Approximately 80% of Mental Health Online and MindSpot consumers accessed a therapist, whereas only 33% of THIS WAY UP consumers had received support from a therapist whilst working through the modules and activities. The number of times consumers accessed therapist-supported services varied. Over one-third of consumers had accessed therapist support between three to four sessions. No consumers of Mental Health Online and THIS WAY UP, and 14% of MindSpot consumers, attended only one session with a therapist. One-third of Mental Health Online consumers had accessed a therapist more than 10 times compared to 1% of MindSpot and 4% of THIS WAY UP consumers. Consumers across groups reported that therapists commonly provided them with counselling, explained online information, and supported working through the activities. Proportionally, more THIS WAY UP (96%) consumers endorsed that the therapist was helpful than Mental Health Online (86%) and MindSpot (77%) consumers. Nearly all THIS WAY UP consumers “strongly agreed” or “somewhat agreed” that the therapist addressed their needs compared to 80% of Mental Health Online and MindSpot users. Over 70% of all consumers across groups “strongly agreed” or “somewhat agreed” that the therapist taught them new strategies or motivated them.

Table 6 Consumer experience of DMHS therapist support, by service and overall
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Interviewees

Consumers who took part in the interviews were also asked about their experience with the support received from a therapist. Over 60% (n = 15) of those interviewed indicated that a therapist was available as part of the digital mental health service they accessed, with 25% indicating there was no therapist involved and 12.5% indicating they received support from their GP.

Of those interviewees who received support from a therapist or their GP, 72% found the experience worthwhile and positive, with half of these consumers indicating that their needs were addressed. Consumers commonly identified that the therapist reinforced online content or provided counselling. One consumer said:

So, the therapist was good. Actually, I had two meetings with her… they were always there to help me to understand what my modules meant, if I needed any help, and what should I do for the week or what part that I should start working on.

Consumer Wellbeing and Satisfaction

Survey Respondents

Consumers were asked about the extent to which digital mental health services improved their health and wellbeing. Approximately 82% of consumers indicated that they had experienced improvements in health and wellbeing, and approximately 80% of consumers attributed these changes to the support they had received through the digital mental health service. Only 4% indicated a deterioration in health and wellbeing.

Consumers were also asked whether digital mental health services were worthy of their time and the extent of their satisfaction with the service. Over 85% of consumers in each service endorsed that the digital mental health service was worthy of their time, very worthy of their time or completely worthy of their time. Approximately 85% of consumers across services were satisfied with their care. For further breakdown, see Appendix 3.

Interviewees

All consumers interviewed (n = 23) indicated that they were satisfied with the care they received and would recommend digital mental health services to others. In terms of benefits, two-thirds of respondents (n = 16) cited helpful content, and 50% (n = 12) mentioned the self-paced nature of the service. Respondents also mentioned the benefits of accessibility and privacy of the digital mental health services. Interviewees made the following comments:

I think it’s helped to clarify things for me – what I was feeling – it wasn’t just me, there were plenty of other people around with similar sorts of problems, and … I don’t know if confronting them is the right word, perhaps understanding what you’re going through and that you can get help if you can know where to find it – because I spent quite some time – they say you should spend 3 or 4 hours a week doing it because I wasn’t doing anything else I was spending probably twice that just going backwards and forwards over it and just clarifying things in my mind and getting out of crisis mode if you like – you know calming myself down is the way to describe it.

Yeah, yes, I already have recommended it to the others, just because it’s like you can access it at your own pace … it’s free, and yeah, it’s an excellent service.

Nearly all the consumers (n = 22) interviewed also indicated that treatment via digital mental health services led to positive changes. These changes were associated with developing insight and understanding of their situation, experiencing improvements in their sleep, mood, and physical health, and improved coping through learning new skills. Some of these sentiments are captured in the following quotes:

There has just been a bit of a deeper understanding, so it has been a positive change.

I’ve literally got no insomnia anymore, and to me, that’s probably like the best thing in the world, like I’m sleeping now, so it’s like wow.

Improvements in Functionality and Use

Consumer interviewees were also asked about the types of changes that needed to be made to improve the use and functionality of the digital mental health service. A variety of difficulties associated with using digital mental health services were raised. One-third (n = 8) of respondents mentioned personal motivation as a difficulty. For example, one consumer said:

The difficulty is maintaining the exercises and making time for it, you know, as you’re getting better.

One-fifth (n = 5) of respondents indicated time constraints on the content as a source of the difficulty. For example, one said:

I think the only thing I would consider changing would be to allow the psychology support to draw out a little bit longer, so maybe it was fortnightly, so you could have two weeks to do a module.

Respondents also mentioned technical difficulties, needing more time with a therapist, finding the content not being individualised and being locked out of the modules as difficulties they faced. Close to 30% (n = 7) of respondents did not identify any problems.

Regarding the types of changes needed to improve digital mental health services, most commonly, consumers highlighted that the promotion and awareness of services need to be boosted. One such consumer said:

It took about five years before I received proper help…I think that it should be advertised more because – the other thing as well is that it doesn’t cost money if you don’t go through your GP, if you just had an advertisement, you know how like when you see flyers in the doctor’s office, I feel like you see all these other ones but you never see anything really about mental health or online services aren’t there… You need to know about it.

In line with the difficulties they experienced, a minority of consumers indicated that the programs could: be simplified; easier to navigate; have more interactive activities; utilise innovative technologies (e.g., apps); and be supported by a clinician or therapist via telehealth. One consumer also highlighted that funding digital mental health services is an ongoing need.

Discussion

Digital mental health services are playing an important role in the Australian mental health landscape.

The findings of the study have several implications for future development and implementation of digital mental health services in Australia. Our findings highlight that most people who completed the surveys and interviews where English-speaking women under the age of 50 years and first time users of the service (Bassilios et al., 2022a, b). This finding is consistent with users of digital mental health services in many middle to high-income countries. It suggests that digital mental health services are addressing unmet mental health needs but perhaps have a limited reach to diverse cultural and minority groups (Bassilios et al., 2022a, b). To address this gap, the inclusion of disadvantaged sub-populations and diverse cultural populations needs to be prioritised in the design, implementation, and promotion of digital mental health services. This may involve adapting interventions to meet the specific needs of these populations, as well as increasing awareness and education about the availability and effectiveness of digital mental health services amongst these groups (Schueller et al., 2019).

Overall, the results of this study also stress that consumers were very positive about their experience with using digital mental health services, despite different models of care. Participants appreciated the accessibility, convenience, self-paced nature, therapeutic support and guidance provided by these services. Most participants found the services to be user-friendly, easy to use and navigate and were satisfied with their experience. However, despite these benefits most consumers were finding digital mental health services on their own via online searches often due to worsening symptoms and lack of access to traditional face-to face mental health treatments. These finding suggest that digital mental health services are not yet fully integrated into the healthcare system, and that the low reach/uptake of digital mental health services is primarily not because of poor effectiveness or satisfaction with them, but a lack of awareness or attitudinal barriers. To promote the use and adoption of digital mental health services, a recent environmental scan recommends providing increased educational and training opportunities be provided for both consumers and mental health professionals on the value and efficacy of these services (Bassilios et al., 2022a). Other engagement strategies might include sending reminders, providing coaching, peer supports and personalised information (Gan et al., 2022). Furthermore, partnering with physicians/clinicians and including digital mental health services as part of stepped care intervention can also help with uptake of the digital mental health interventions amongst consumers (Whitton et al., 2021). The Australian Government has also recently released the National Digital Mental Health Framework that defines specific objective and action areas that includes some of the above strategies to improve access and integrate digital mental health services.

Study Limitations

The recruitment process for this study has the potential for bias, as the digital mental health services acted as intermediaries in identifying and recruiting participants. This method may have resulted in a sample of consumers who only have positive experiences or who are motivated to promote the use of digital mental health services. It also relied on self-report. However, the sample of consumers our study is consistent with the population of individuals who use digital mental health services globally (Wozney et al., 2017).

Whilst this study’s findings accord with previous research suggesting that digital mental health services are well received by users, the sample consisted of users engaged with these services who were also keen to participate in the evaluation. Therefore, the views of this sample may not represent the views of broader potential users and non-users of digital mental health services.

The outcomes observed are specific to three Australian public-funded digital mental health services that include the option of clinician support: This WAY UP, MindSpot, and Mental Health Online. Each service has its own interface, design, and content, so the findings might not be generalisable to other digital mental health services.

Although the sample size of 351 participants in this study is relatively large, it should be noted that it only represents 11% of all consumers invited to participate in the survey. Commonly response rates for primary health studies range from 10.3 to 61% (Booker et al., 2021). Our response rate may limit the generalizability of the findings. However, it is important to note that despite the low response rate, the consumer demographics in our study are mainly similar to those of the broader users of these services. Our sample was primarily English-speaking females (73%) under the age of 50 years, with approximately 5% being Aboriginal or Torres Strait Islanders. Just over two-thirds of consumers who register with Mental Health Online are female (68%). Most (70%) are young adults (18–34 years), with around 25% aged 35–54 years and 5% aged 55 or older (Thomas et al., 2019). Similarly, 73% of MindSpot users are female, with an average age of 36 years; almost 4% are Aboriginal or Torres Strait Islander peoples, 22% are born overseas, 19% reside in rural or remote locations, and 32% are from New South Wales (Titov et al., 2020). Likewise, two-thirds of THIS WAY UP users are females, with an average age of 29 (THIS WAY UP, 2021). Although the trend of users who engaged in our research primarily represents the distribution of the Australian population, there might also be a location bias, and the results might not represent the diverse perspectives of other states across Australia. Lastly, the response rate per service is proportional to the uptake of each service; i.e., service uptake is highest by THIS WAY UP and lowest by Mental Health Online.

Five percent of our study population consisted of First Nations people, which aligns closely to the digital mental health service reach of First Nations people in line with the national census proportion. This suggests that these programs reach diverse populations and we have captured some of these consumer experiences. However, given that our study only included consumers who can read and speak English, which is representative of the users of digital mental health services, the applicability of the findings to individuals from culturally and linguistically diverse backgrounds is limited.

We recognise that these individuals’ needs may differ, and further research is needed to ensure that digital mental health services meet the needs of all users, including those from diverse cultural and linguistic backgrounds. This could include conducting research in multiple languages, or working with qualified interpreters, to ensure that the data is accurately collected and represented.

Conclusions

In conclusion, digital mental health services have a vital role in mental health care provision. Consumers who access care through these services appreciate the convenience, self-paced nature, therapeutic support and guidance provided by these services and are noticing improvements in their overall mental health and wellbeing. Further research is needed to examine how digital mental health services can cater to the specific needs of disadvantaged sub-populations and diverse cultural populations and be seamlessly routinely implemented in mental health care systems.