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COURSE DETAILS
Course Code: HLTH2000

Course Name: eHealthcare

Course Co-ordinator: Dr S Edirippulige

Assignment No: 3
Assignment Due Date: 7th June 2015

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Student Number: 43183526

Student Name: Khang Nhan

Address: 1 Holyrood St, Calamvale

Email address: khang.nhan@uqconnect.edu.au

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Mobile: 0490090016

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Date: 9/06/2015

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Filling the gap of depression and

mental health care in rural
Australia with an e-health
solution: Computerised Cognitive
Behaviour Therapy
Background
Depression is a debilitating mental illness that predominately affects young adults. In
Australia, 1 in 16 young adults suffer depression while almost half (45.5%) of the total
population will suffer a mental health condition during their lifetime [1]. Depression is the
third highest burden of disease in Australia [2], as measured by the total impact of a disease
by financial cost, mortality and other factors, and indicated by the World Health Organization
as a major contributor to the global burden of disease [7].

Depression in rural Australia and associated rural issues

Moreover, depression is a relatively greater issue among rural populations in which medical
clinics are scarce and much needed mental health facilities and professionals are lacking [17].
This is an unmet need which requires amendment as rural populations exhibit identical [3] if
not higher instances of depression [4]. This is also worsened by the lower amount of GP
encounters [10], particularly for psychological problems, in rural areas, which greatly
increases the possibility of completely untreated mental health issues. Ultimately, the
inadequate attention and treatment of depression can have detrimental effects on individuals
and their families as it also poses a high risk for suicide [8]. This is reflected in the 2.7 times
higher suicide rate in rural communities than urban communities [18]. It is therefore
paramount to provide access to highly required mental health therapy to affected individuals
in rural populations.

Stakeholders of depression
Depression and mental illness is a widespread disease that can affect any persons of any sex
and of any age. Moreover, depression is estimated to cost the US $36.6 billion per year is
absenteeism and presenteeism[8]. This indicts not only the individuals and their families as
stakeholders of depression, but also the economy, emphasizing the detriment of depression to
society.
The young population is the most affected by depression and mental illness, as the age group
consisting of 14-24 report the most instances of mental illness [5]. In rural areas, the lack of
widespread mental health facilities and professionals exhibit a great deficiency compared to
their metropolitan counterparts. It has been reported that lack of accessibility in terms of
reliable transport to available mental health services has affected its utilization by rural young
people [6]. Additionally, it was also reported that rural gossip networks and social visibility
within the rural communities, compounded the stigma associated with mental illness, and

thus negatively impacted their utilization of mental health services. Therefore, a health
service that is highly accessible and convenient while also confidential, is required to
efficiency provide young adults with much needed mental care.
Likewise, the rural elderly population is also subject to similar difficulties as the youth in
terms of barriers to obtaining mental healthcare. A study conducted by Muir-Cochrane et al.
[9] investigated the problems and needs of the rural elderly via an interview. It was found that
perceived stigma was a pertinent issue among the elderly who were reluctant to admit
potential mental health problems. This was exacerbated due to the small nature of rural
communities and their consequential social interactions/talk. Unwillingness to admit a
problem was further emphasized due to stoicism, which was particularly evident in older men
who viewed mental illness as a sign of weakness. This is also a common theme in farmers
and younger men who are less likely to seek help due to their resilient nature acquired from
their occupation [reference]. Furthermore, the elderly also expressed agreement that the
attitudes of health professionals also affected the identification and diagnosis of mental
illness. It was noted that health professionals tended to focus on physical illness in
consultations with older people, while dismissing indications or patient concerns on mental
health problems. Participants of the study were unanimous in that separation of physical and
mental health service provision was detrimental to older people and that an integrated
approach would better suit their needs. Lack of accessibility to specific mental health clinics
due to rural settings was also an issue for effective service provision for the elderly, in which
insufficient transport further hindered their ability to access needed services.
Therefore three common needs are apparent for individuals in rural areas who require mental
health care: 1) specialized mental health care professionals who are 2) easily and 3)
confidentially accessible by all people.

E-health solution: Computerised Cognitive Behaviour

Therapy (CCBT)
With the abundance of available technology in the current era, accessibility of health via
telehealth means is an emerging field. Young and old people alike are able to access digital
technology, such as computers, which thus enables a platform for the administration of health
programs. Computerised cognitive behavior therapy (CCBT) is cognitive behavior therapy
(CBT) delivered using a computer. CBT is a form of psychotherapy most effective for
depression and anxiety-based mental illnesses which aims to change the way in which a
sufferer thinks, and thereby changing behavior and emotional reactions. This process is
traditionally administered with a therapist and is supplemented by manuals and audio and
video media. CCBT however is mainly in the form of a computer program, of which there are
many, designed in tandem with; specialist mental healthcare professionals, individuals with
specialist knowledge on issues affecting people with depression and anxiety, and associated
organizations representing views of people who are affected by the guidance (e.g. carers of
sufferers) [11].
The computerization of CBT, CCBT, eliminates the need for rural sufferers to extensively and
repetitively seek and travel to access specialist mental healthcare, and is easily accessible
immediately and conveniently from their home computer. This also appeals more to the
younger sufferers who are more comfortable and proficient with such technology.
Additionally, using the CCBT adds an element of confidentially for depression sufferers as
they are not required to constantly attend therapy sessions, avoiding social interactions and
perceived stigma, thereby appealing to both young and old sufferers of depression. The

nature of the program thus can act as a replacement for, or preferably, in conjunction with,
basic or clinical mental health care, and can be simply suggested by rural general
practitioners.
The CCBT is already recommended for use in England and Wales by their respective
National Institute for Health and Clinical Excellence guidelines [12]. It is used as a form of
low-intensity, to mild or moderate depression treatment. Other studies have shown that CCBT
addresses confidentiality concerns of rural patients and is equally effective between rural and
urban participants [13]. It is important for healthcare professionals recommending these
programmes to depression and mental health sufferers to ensure regular checkups as to
eliminate potential concerns of dismissal, and to assess progress of the treatment and whether
an alternative program; CCBT or other, is required or more suitable for their condition.

Limitations, Risks and Barriers

Although CCBT has shown to be an effective depression and mental health treatment, some
mental professionals could be skeptical of its efficiency. Some practitioners will be dissuaded
by its use due to CCBT not establishing traditional therapeutic relationships between clients
and has reported according to a study [14] to be relatively less helpful in terms of facilitating
problem-solving and developing understanding. Alternatively, another study [15] involving
21 rural Australian clinicians revealed a preference for the integration of online health
resources, such as CCBT, to supplement existing services. However, implementation of
CCBT will extremely and mostly useful in rural areas in which specific mental healthcare is
scarce or devoid, and should be used in accordance with clinical advice. The relatively new
approach and consequential lack of documentation of CCBT will limit the information
available to clinicians and program deliverers, thus further acting as barrier to its
implementation.
As these programs are generally produced by third party organizations, they are generally
accessible by any persons regardless of a medical referral. Therefore, social referrals between
sufferers of depression are probable, which, although potentially positive, may lead to
negative consequences in instances in which CCBT does not work, potentially dissuading
from seeking further medical attention. In addition, these social referrals will not be utilized
with medical guidance, and thereby suboptimal.
Immediate costs will also affect its implementation in the form of training and government
funding in terms of purchasing the programs from organizations. However a budget analysis
of telemedicine-based care for depression has shown there is no disincentive for mental
health providers to offer such care as it does not increase total workload for primary care or
mental health providers.

Monitoring and measuring effectiveness of the CCBT

CCBT is an e-health application that is computerized. This thus allows for easy gathering of
data and information. Usually used as co-treatment with traditional therapy with a therapist,
primary and secondary health outcome endpoints should and can be easily measured.
CBT with a therapist will always continue with a patient over a sufficient time in which the
depression is managed and cured. Therefore, CCBT is conducted over an identical period.
The primary endpoint and effectiveness of CCBT can then be measured post-recovery of
depression via many means, such as a survey conducted by the therapist, or through the

CCBT program itself in which it may prompt the patient to answer a survey with the
incentive of helping other sufferers and their depression. Patient satisfaction can also be
indicated via the clinician delivering the treatment, and their constant assessment of
improvement of the patients mental state.
Secondary endpoints can be assessed inherently by the CCBT in the form of questionnaires or
surveys built into the programs. Such example may be a questionnaire prior to use which may
prompt the user on how they were informed of the programs; by a clinician or friend, and
where they reside; rural or urban. Annual surveys may be conducted on rural clinicians
assessing overall patient encounters for psychological illness, particularly for sustained bouts
of depression. This program may further identify and solidify common mental health issues
among rural populations, which may or may not differ from urban populations, and add and
reply to literature that suggest more research be done on rural Australians and causes for
depression.

Conclusion
Depression is a common mental health issue that affects all ages of the population. One of the
leading causes of disease burden, it is a major issue for all health professionals. Although
recognized as a major health issue globally, sufficient mental health care is lacking in rural
areas of Australia. With already lacking medical facilities, staff, and specialist care;
depression and mental illness treatment is also insufficient, which, if left untreated, may lead
to suicide; evident in the difference between suicide rates between rural and urban
communities. To rectify the need of more accessible depression and mental illness care, an ehealth proposal was suggested; computerised cognitive behaviour therapy. It addresses the
three major concerns of rural Australians in regards to mental health care; adequate specialist
mental health professionals, easily accessible, and confidential, therapy. Computerized
cognitive behaviour therapy is designed by mental health professionals and associated
organizations, and suggested to be used in tandem with clinicians to provide succinct and
effective depression and relative mental health issue treatment. This reduced required therapy
sessions with a clinician, assisting in confidentiality and thereby eliminating social stigma. As
the programme is electronic, it is also easily and comfortably accessible by a home computer,
and so readily and conveniently available. Although, there are impediments to its
implementation in that its success and use is not widely documented, and that it eliminates
slight portions of traditional cognitive behaviour therapy in that therapeutic relationships are
not as strongly developed. If implemented however, effectiveness is easily monitored via
surveys as computerized cognitive behaviour therapy should be used and cease use in
accordance with medical guidance, and so appropriate surveys can be timely conducted, i.e.
when depression is conclusively treated. Moreover, its widespread implementation in rural
Australia would provide much needed mental health care among the community in which
depression and stigma towards mental health illness is rife.

Reference List
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