Episode 42: Exploring digital interventions for mental health

Dr. Caroline West: 
Hello and welcome to the NPS MedicineWise podcast. I'm Dr. Caroline West. I'm a GP and a medical advisor to NPS MedicineWise. When it comes to mental health issues, young people can be particularly vulnerable. You may be surprised to know that more than 50% will experience some form of mental ill health before the age of 25. COVID has certainly increased the stress levels with disruptions to work, study, travel and social connections.  Early interventions with effective support, engagement and management of course can make all the difference. Psychological treatments are often in the mix yet, accessing psychological support can be difficult, especially for those in rural and remote areas, but even in cities, too, access can be a problem, and this is not to mention the cost for many young people. So what are some other options to consider? How can we improve access? Today, we'll be talking with a psychiatrist who is a champion of digital mental health services. Dr. Michael Millard is the director of the clinical research unit for anxiety and depression at St. Vincent's Hospital in Sydney. And is the director of THIS WAY UP, a not-for-profit, which delivers evidence-based, internet-delivered cognitive behavioural therapies. No conflicts of interest have been declared. Welcome to the program, Mike. 
 
Dr. Michael Millard: 
It's great to be here. 
 
Dr. Caroline West: 
Can we start by perhaps painting a picture of what it's currently like for young people in that 16 to 24 year old age group in terms of their mental health? 
 
Dr. Michael Millard:
I think what we've seen is an exacerbation in already existing problems. Right across the community, we've seen extraordinary increases in levels of distress. And in fact, you are hardly able to open a newspaper once a week without seeing an article about the tsunami of demand that is existing in terms of mental health and distress. And the articles always build up the problem, which we've all experienced because we've all been participants in the pandemic where no one has been observing it, and they express the problem and then they get to the end of the article, and then there's calls for things such as, we just need more clinicians, or we need more services, or we need more psychiatrists. And they're true, however, they're things that'll take years and years and years to develop and to create and to foster. And not one I've read has talked about alternatives or the fact that Australia are world leaders in digital mental health. 
 
Dr. Caroline West: 
Well, it's very encouraging to hear that we're at the front of that curve in terms of our digital mental health. And I guess what you're talking about here, Mike is psychological therapies. Can you take me through what you mean there? 
 
Dr. Michael Millard: 
The sorts of digital mental health treatments that we're talking about, and I use the word treatment very importantly, because it's been very difficult to get the message across that there's mental health tools or digital tools and there's digital treatments and they're actually two very, very different things. 

Dr. Caroline West:  
You mentioned that there is a difference indeed, between mental health tools and mental health resources. What do you mean by that? 
 
Dr. Michael Millard: 
I speak to a lot of clinicians and a lot of clinicians aren't aware of the differences. And a lot of clinicians aren't clear about the different sorts of programs or different sorts of resources that are available online and I think that that's a big problem. Yes. So I think as clinicians, it's just important for us to get an understanding. So a digital mental health tool is usually something that has, I guess, a single thing that they do. A great one to be aware of is the Beyond Now app, which is safety planning. 
 
Dr. Caroline West: 
That's a fantastic app actually. I've used that a lot with patients and had a really good response with it because it's always on their phone. It's something that you can engage in that gives them a framework around risk and safety. Very positively received. 
 
Dr. Michael Millard: 
Exactly. 
 
Dr. Caroline West: 
Yeah. 
 
Dr. Michael Millard: 
Yep. And then when I talk about, and when we are talking about treatments, these are full treatment packages. So it's the equivalent of full courses of treatment and that's what they've been trialed for and that's what the evidence supports. So I think that that message is not necessarily getting across. And it's going to become more and more important because I think there's about 400,000 mental health apps on the Android, in the app store. And how the hell do you know what's safe, what works, what's got evidence behind it? One of the things that I'd encourage people to keep an eye out for are interventions that have met the digital mental health standards. So this is new and it's from the Australian Safety and Quality Commission. And it's Australia's first step in recognizing the importance of the security of apps, the cyber security of apps. I always think in my own mind of those old photographs on the bus of some dodgy kind of meth lab setup, and it's like, "Would you buy your medication here?" Well, digital's exactly the same. So we've got a whole lot of interventions that are made by people that have no clinical experience, that are not backed by research, that are selling data, that don't have appropriate privacy policies. And I think that as clinicians, it's very important to start to recognize this because it's important, because consumers and your patients will be turning to you and your endorsement of something is as legitimate with medication as it is with these digital interventions. So keep an eye out for that. It's a moving space. And I have yet to meet someone, who's read the privacy policy of any app that is on their phone, but in mental health, it's extremely important 
 
Dr. Caroline West: 
On that point, how protected is the data for those who register with THIS WAY UP? That will be a question asked. 
 
Dr. Michael Millard: 
Yes. So we, and pride before a fall that I say this, are like Fort Knox. We have the joy of being inside a public hospital that takes this immensely seriously as we do. So I think that this is one of the things that's very important for organizations to think about, who are working in this space, is that firstly, you need to be secure. Secondly, mental health data is immensely private and it needs to be treated exactly the same way as a hospital would treat your paper file or would treat your health record. And that's one of the wonderful things about meeting the digital mental health standards is that's one of the pillars of it. So that's why it's important to look out for this because it's actually a complex area and it's one where society has been asleep at the wheel in terms of any online intervention. 
 
Dr. Caroline West: 
That explanation has been really helpful because I often get asked that by patients, what's happening with my data, how are you protecting it? Is information encrypted? All of those sorts of things. And sometimes to be honest, I'm not entirely sure of the answer. So you've explained that really well. Thank you for that. As you say, too, there are so many competing ... What did you say, 400,000 mental health apps? 
 
Dr. Michael Millard: 
Yep. 
 
Dr. Caroline West:
I mean, I've been sort of ... foolishly purchased one, I remember, and it was for a relaxation series and essentially after I'd purchased it, I found out that it was just essentially somebody doing some deep breathing. And at the end of the deep breathing, there was a bit of a gong. Certainly not evidence-based and certainly I felt as though I'd been diddled of my few dollars. 

Dr. Michael Millard: 
Yes. Unfortunately not a rare experience. 

Dr. Caroline West:
No, I felt a bit sheepish, but I think often in the moment you think, oh, that could be good. And I think a lot of consumers go down that path, don't they, of been enticed by the promise of an app that may look as though it's legitimate and actually be not meeting any of the claims that it posts. 
And we'll be deep diving into this a little further, particularly in the organization that you're a part of, THIS WAY UP. But if we can just backtrack for a moment in terms of what are some of the more general barriers, if you like, to accessing management for young people with mental health issues? What are they up against? Because it's not just about access, is it? It's also about, I guess awareness, it's about stigma, it's about feeling safe, respected. 
 
Dr. Michael Millard: 
Absolutely. 
 
Dr. Caroline West:  
Can you take me through that? 
 
Dr. Michael Millard: 
Absolutely. And look, we know that on average, it takes over eight years for someone who's living with clinically significant anxiety and depression to be brave enough to take that first step to ask for help. So that's the person that's sitting in front of you in the consult room. 
 
Dr. Michael Millard:  
So eight years to get help, and there's a lot that's gone wrong in the meantime. So we've improved a lot. So we've had a lot of work with awareness, but we haven't improved a lot at that point of eight years. And one of the biggest barriers is that once you get through that door, is that what happens next. And hopefully we'll be talking a little bit later about the different options of what happens next and how important that moment is in changing the trajectory of that person's journey through the mental health system, which is immensely complex.  And when you talked about the numbers before, so just for anxiety and depression, it's a 50% lifetime prevalence for all of us. So if it's not you who's making that step and asking for help, then it's someone that you love and the barriers are the same across the board. So whether it's regional and remote areas where there aren't options for people. Or it seems like much of our mental health system has a no right door option. So we talk a lot about having a no wrong door, a lot of our mental health has a no right door option. And I say that where I am certainly in my clinical experience when I've been trying to even make referrals myself, knowing a lot about the mental health system, I get knocked back by everybody's eligibility criteria, or it's not for our service. Then of course, other services like Headspace who have an open door policy, I'm yet to talk to a Headspace that doesn't have a waiting list of 70 to 100 young people who are waiting for help. So there's a lot of people who are holding out for help at the moment. 
And it's no wonder that when they do come to us and they're sitting in front of us, they're distressed. We know they're distressed, we validated their distress, and we think about what next. No wonder it's been so much part of the plan, has been the prescription for antidepressants, which we can talk a little bit more about in a moment. But I think partly what's been driving a lot of that is we haven't had a lot of other options that we've been able to access or been able to direct people to. 
 
Dr. Caroline West: 
And so just on that point of antidepressants, do you think that perhaps for this age group, they are being over-prescribed because clinicians feel as though they've got no choice or they feel as though they want to do something? 
 
Dr. Michael Millard: 
I absolutely do. And I say that both from, I guess a broader level of looking at statistics and the ways that the medications are, I guess, encouraged to be prescribed by clinical practice guidelines and the numbers. And I also know that as having been a young GP before I was a psychiatrist and I've had the person sitting opposite me and I've really felt that I've needed to do something and that's been one of the main tools that I've had, rightly or wrongly at that point. 
 
Dr. Caroline West: 
And I guess that the numbers are increasing for prescriptions of antidepressants in very young age groups now, which I know has surprised me enormously because when I started in general practice, it was very rare to see somebody under 18, it was exceptionally rare to see somebody even younger than 16 on an antidepressant. 
 
Dr. Michael Millard: 
Yes, and it's not just one antidepressant that we're seeing people on, it's multiple antidepressants that we're seeing people on augmented with antipsychotics. And I agree that it was previously very rare for under 18s to have had this approach and child and adolescent psychiatry has been very much about the fact that it's behavioural and family interventions that come first and then medication was really just kept for severe distress or for severe Axis 1 disorders. So we have definitely seen a shift. And in the NPS's own leaderboard, we've slowly been seeing sertraline tick up the scale from, I think last year it clocked in at number nine as the first antidepressant to enter the scale and it made its way up to number seven, I think on this year's release. So that shows that this is a growing problem. 
 
Dr. Caroline West:  
And as you say an antidepressant is now on the top 10 list of medications prescribed in Australia. For listeners, that is published annually and it gives us a snapshot of the health of Australians in many ways to see what's actually pushing up the charts, if you like. And I guess that people have watched that rise of antidepressants with great interest, particularly when people under 25 have this situation, their brains are evolving. The evidence base in terms of the research has often been skewed towards an adult population, not a 16 to 24 year old population, where their needs and the neuroplasticity of their brain may mean that different approaches are required. Do you have a comment on that sort of area? 
 
Dr. Michael Millard: 
I think that's absolutely correct. And when I've thought about the reasons why this might be, it's almost we're a product of our own success in terms of the way that we used to talk about selective serotonin reuptake inhibitors. So certainly when I was training in medicine, certainly when I was a junior doctor, it was very much about the serotonin hypothesis. It was a beautiful explanation that we could give about if you're a diabetic that you would take insulin, here is something that will be helpful. And I think that we've very much socialized people into an expectation that that is going to be the case. I have young people coming in to see me who straight up are attending because their friend is on an antidepressant or they would like an antidepressant. It actually takes me a lot of time to explain to someone why that might not be the right choice for them. Now, I say that, but I also say that I'm not anti-medication, but I'm definitely all for the appropriate use of medication and none of the clinical practice guidelines talk about medication for mild disorders. It's rare to find that medication, it's an either or usually for moderate disorders in terms of psychological therapy and you can give the choice of an SSRI, but for severe disorders, yes, absolutely. The evidence is great for antidepressants and they're very appropriate. But they should also at that point, that's really where you throw everything. So you have your medication, you have your lifestyle modification, you have psychological therapy, and hopefully you'll add in your digital mental health treatment as well, which we can talk about in a bit. 
 
Dr. Caroline West: 
So the first line management strategies for those with mild to moderate mental health issues in that young person cohort really involve lifestyle interventions, as you say, and very often psychological therapies. I know that a lot has been talked about with psychological therapies and it is ideal when you can find a face-to-face therapist, who can see you in an area that you happen to live in Australia, at a price that's affordable. But I've spent a lot of the last two years working out of Broken Hill, in rural and remote settings in the whole central part of Australia and I've managed many young people in distress, and it's really hard to get any face-to-face consultations. And then when they're stung with the, oh, and there's 100 dollar gap per consult, they nearly fall off their chair and they go, "Well, where am I getting that money from? I've hardly been employed through COVID. Can't I have it bulk billed?" Oh no. So it's an immediate barrier. And as you say, if you can't get access and you feel as though you've been financially snubbed, that's a pretty cruel message to be sending to people who are feeling it. 
 
Dr. Michael Millard: 
Oh, I absolutely agree. And just thinking through that, and I think it's very important for every clinician to have a good understanding of what are their local circumstances. So one of the best things that I've come across this year was a report by Lived Experience Australia that they produced that was on the state of psychology, where they asked consumers and carers what their experience was. You mentioned that it was a 100 dollar gap fee. Well, actually it's a 176 dollar gap fee on average for one consultation. And if a young person has a significant problem, they don't need to see the psychologist once, they need to see the psychologist multiple times, if they are going to be working toward making changes or being supported in their life. So at 176 dollars a pop gap fee, that's a serious amount of money. The APS fee is 267 dollars per psychological session, so that works out roughly with a gap of 176. That's a psychologist, we're not even talking about psychiatrists where the AMA rate will be 440 dollars for that young person for that consultation for an initial appointment, and 395 for a follow up appointment. They're real things to understand in terms of costs, and then of course, it's the wait. The other thing that I see a lot is that young people will go see their local practitioner. They get a mental health care plan, which is fantastic. They get referred to the local psychologist, which is fantastic. They wait the seven weeks, which is probably a conservative wait at the moment across the country. I think it's actually much longer depending on where you are. They finally get to the seven weeks and they get the appointment. They've had it, they're like, "This person's nice. They understand me. I think they'll be able to help me. When can I see you again?" And they're like, "I can't see you for another six weeks." This is like going to the gym and seeing your personal trainer once a month. So we're in dire strait when we look at what actually accessing mental health support is like at the moment. It is extremely difficult. And if there's one thing I can encourage you to do, it's work out what's happening in your area. 
 
Dr. Caroline West:
And this is where digital solutions can come into their own. We probably need to think about a redesign of the whole system in terms of what's available for people to access and what's available for health practitioners to actually provide in terms of management options. What can we think about there that's in a way, doing things differently? 
 
Dr. Michael Millard: 
Well, I spend a lot of time talking to people about using digital treatments to complement the existing system. So we have a lot of GPs, and in fact, we have, I'd have to say, one in three GPs is registered with us to integrate the digital treatment into their treatment plans. So you do your mental health care plan. And what I say is just do whatever you would normally do. So sure, if you're going to go with a script of Zoloft, go with a script of Zoloft. If you're going to do the referral to the local clinical psychologist, do that. So do all of that, but add into that a digital treatment that that person will be able to leave that appointment, to be able to go home that night, log in and be able to start learning about firstly, what they're experiencing. So firstly, the digital treatments provide a whole lot of psychoeducation. And then secondly, they're able to learn the types of skills that they would learn in therapy. And then by the time they get to the therapist seven weeks later, they've already had a whole series or a whole treatment with cognitive behavioural therapy before they even get there. So they're light years ahead of where they would've been otherwise. 
And of course we know because we see the data that a lot of people, when they get through the program do not need to go on to have more intensive treatment. So that means that the people who do will be able to get there quicker. 
 
Dr. Caroline West: 
For those who are not familiar with the THIS WAY UP concept and the website and what you can access, can you take us through what it looks like? I've been on there myself and had a look at the programs. I'm a GP, I understand how it works, but for a lot of people this will be new. And I was very impressed you've done I think, is it 160,000 programs? 
 
Dr. Michael Millard: 
Yes, we're just about to clock into 160,000 Australians that have used one of the programs, so it's quite extraordinary. And as I mentioned, we now actually have a community of over 27,000 clinicians across the country who use THIS WAY UP as part of their treatment. And that's GPs, psychologists, other allied health nurse practitioners, and counselors that are using the programs to complement what they're doing in a variety of different ways, which is what we've worked hard to do. We do online cognitive behavioural therapy. So cognitive behavioural therapy of course is about understanding how your thoughts, feelings, and behaviours are all connected. And then it teaches lots of skills to be able to change that or be able to learn the way that they're all connected and be able to shift things. So cognitive behavioural therapy is absolutely perfect for delivering on the internet because it's a didactic therapy. So when you go and see a face-to-face clinician, they will teach you the skills, they will then give you exercises and your job is to use the skills in your own life outside of the therapy room. So the magic of cognitive behavioural therapy happens when you practice the skills out in your own life. So this is why it's so amenable to being taught by an online program. So our programs they were based, or they are based on what we do in our face-to-face clinic at CRUfAD and the New South Wales anxiety clinic. And the story of our service is that we took what we did face-to-face, it was manualized. I know a lot of people would've used CRUfAD's CBT manuals at some stage in their training or practice. And the manuals were used at that time in a group program. Along came the internet, so they were placed on the internet.  They all follow an illustrated storyline of several characters who have symptoms like yours. And the programs follow an arc over six modules that are designed to be completed over about eight or nine weeks. And you follow and you learn the skills that they learn to take control of their wellbeing. So it exactly mimics what happens in a course of cognitive behavioural therapy when you're having it face-to-face. Now, the thing that I guess I always struggled with is I'm a clinician and I like seeing people and I like to think that I'm very important. Unfortunately, the research has shown that the programs are equally as effective for someone with a disorder as face-to-face cognitive behavioural therapy delivered by a clinical psychologist. And that's actually extraordinary, when you think about it as an option to be adding into our armory of treatments. 
So they work, they're accessible. It doesn't matter if you're in Darlinghurst or Dubbo, you will get exactly the same treatment using one of our programs. And as I say, there's very few area in medicine that is as evidence-based as digital mental health. And I can speak on behalf of the two big programs in Australia. So there's MindSpot, of course, which some of you might be familiar with and there's THIS WAY UP. Both those services are among the most evidence-based services in the world in terms of internet-based cognitive behavioural therapy. So all of the programs are created firstly with consumers and with expert clinicians. Then secondly, they're run through randomized control trials, which is exactly the same way that drugs are trialed. And then the next step that we do is we also publish our effectiveness data. So that would be your post-marketing surveillance data for antidepressants, for the scientists who are following. And we publish all of that. So that's our real world data that says that the program is working exactly the way that we expect it to in the community, as it has done in our RCTs. So that's extraordinary. And of course the RCTs are now meta analyses and there have been network meta analyses that show that they work. So it's extraordinarily evidence-based in terms of an intervention. And this has been reflected by the fact that the College of Psychiatry has placed digital mental health treatments as non-negotiable treatments for both anxiety disorders and depressive disorders. And so it's quite extraordinary when you think about it. 
 
Dr. Caroline West: 
That's an incredible shift, isn't it? In terms of our thinking, because as you say, there was probably early skepticism in the clinical community about how useful these interventions would be. And yet, as you say, your research has shown that they are extremely effective and extremely cost effective. So if we get back to this big picture situation with mental health services in Australia, we've got this real issue, not only with accessibility, but affordability. This is a great solution. 
 
Dr. Michael Millard: 
That's right. And again, just going back to costs, if I fit that back into what we're talking about, the cost of a psychologist. So a standard treatment of CBT for a face-to-face clinical psychologist, we could say 10 sessions just to keep my maths easy, that's 2,670 dollars that that's going to cost that young person. But I think that we have to have a frank conversation with our patients about waiting lists. We have to have a frank conversation with our patients about the cost of medications and we have to have a frank conversation about side effects and we have to have a frank conversation about what it might feel like to stop our medications. And I love the fact that the thing that I am passionate about is shown to be helpful, work, and doesn't have any side effects. 
 
Dr. Caroline West:  
Yeah, and the side effects for young people can be really debilitating, sexual dysfunction, agitation, increased suicidal thoughts when you go on a medication. I mean, it's not a nice suite of side effects. They can certainly be a turnoff and often lead to discontinuation of therapies. 
 
Dr. Michael Millard: 
Absolutely. And I don't think we do that well enough as practitioners. We don't have the conversation about that, unfortunately. Hopefully things are shifting, but there's a lot of work to be done. 
 
Dr. Caroline West:  
Yeah. I think things are definitely shifting and NPS MedicineWise currently has a program for engagement and empowerment for young people with their mental health. And we've had a very positive response from clinicians because they're very eager to know more about this area because obviously they sit in that chair in the consultation room every day and they're seeing young people coming in with distress and want to be able to work in partnership with young people and they're hungry for information about how they should direct their efforts. 
 
Dr. Michael Millard:
Yes. And I think that the bigger your armory, the better in terms of the treatments and things that you can offer. The other thing that's wonderful, that's floating around is this idea of social prescribing, having an idea in your area of ways that young people might be able to increase their social connectivity. I mean, parkrun's a fantastic example of that across the country,  

 
Dr. Caroline West: 
It's interesting that you mentioned that about social prescribing and indeed earlier in the podcast, you talked about lifestyle prescriptions in a way. And often they were ignored in early treatment plans 20 years ago because it was seen as a soft side of medicine and that was just something that you needed to intuitively follow your nose with, you didn't need to talk to your patients about that in any specific way. What are you doing in terms of lifestyle suggestions at THIS WAY UP in terms of sleep, for example? 
 
Dr. Michael Millard: 
One of the programs that I'm most proud of that we offer is our insomnia program. It is an enormous problem across the community and clinicians will know from just seeing people coming in. They will know themselves ... I speak to a lot of clinicians who have insomnia. It's interesting actually watching what's been happening in the UK, because the NICE guidelines are being rewritten and people are becoming more aware of what's called CBTI. Now in this case, it's for CBT insomnia and that is an immensely effective treatment for insomnia. And it's light years ahead of what we traditionally have thought of things, like sleep hygiene. I certainly remember going to perhaps the Sleep Foundation and printing off a handout for someone and going, "Oh, here, this will help you and fix you," probably as I passed over the prescription for Zolpidem and then moving on. 
 
Dr. Caroline West: 
So you're saying that sleep hygiene has been sidelined for the way that we think about our wakefulness in the middle of the night or our busy brains? 
 
Dr. Michael Millard: 
If we think about sleep hygiene, it's like a crumb compared to what CBT for insomnia is. And our program, it's four modules. Anyway. Our program, it's four modules and it's really based on this idea of sleep restriction and it works. We've run it through an RCT, it works. So it's very hard to find a clinical psychologist who actually does CBTI. So here you have this intervention available on the internet that works, that will teach your patients or yourself how to sleep by using very, very well researched psychological strategies. And it's one of the things that we are most proud of and one of the things, if you just want to dip your toe into digital interventions, this is the one to start with. So next time when you're sitting there, do whatever you normally do, give them the sleep hygiene handout, give them whatever you're going to give them, but also tell them, go to the website. There's a four module program on there. It will help. And I look forward to their response. 
 
Dr. Caroline West: 
So joining me today is psychiatrist, Dr. Mike Millard. Can I just take it back to some of the other disruptors for sleep while we're talking about sleep? Because I often get asked by people, well, with young people is social media to blame in terms of being a great disruptor in terms of mood and sleep. And I mean, what should we be thinking about in terms of that? 
 
Dr. Michael Millard:
The older I get, the more I end up being on the side of the answer is yes, it is not helpful. I wanted to not say that, but unfortunately, it has taken the worst of what we have might have seen previously and it's been amplified. It's clear that it affects the way that we think about ourselves. It is clear that it affects our body image. It is clear that it disrupts our attention. It is clear that it affects dopamine firing in terms of the continual spikes of dopamine with scrolling. It is clear that it is being used by people a lot as a way of distracting them from other difficulties or of self-soothing. And unfortunately, that is what we're seeing. That said, of course, it's been revolutionary for people in so many other positive ways. And we always in psychiatry like to avoid thinking that something is totally bad or good, but certainly anything can become harmful depending on how it's been consumed and used. In sleep, if you're not sleeping and your way of managing that is to pick up your phone and just spend a few moments on Instagram, 45 minutes later, I'm sure you'll be putting that phone down. And it interferes, it interferes. And that's actually, we're talking a sleep hygiene technique now, but they're real things. And I think that the social media companies are getting better at what they do. And we can even see, I think that the fact that a lot of devices give you your screen time now. And if you haven't looked, please look at what your screen time is and I think you might be shocked with actually what that information is that comes back. We run a digital mental health service. One of our core mantras is we want you to get off of your phone and into your life. And I see so much that social media and gaming does not do that. 
 
Dr. Caroline West: 
And as you said, there's a lot of overlap between gambling and social media in that the hits to your system are designed to entice you back and stay for more with the scrolling. 
 
Dr. Michael Millard: 
Absolutely. It's a lot of the same concepts, they're actively being used. And that's when we talk about adherence and engagement. It's another thing that's fascinating in working in digital mental health is people say to us, "Oh, well, what's your adherence rate?". And I can tell you that we can create a mental health app that has beautiful adherence, that'll get people to pick it up every day to do whatever we want, get them to engage with the platform and we can say that it's fantastic adherence, but we're not looking at the right metrics. And a person can engage with this digital mental health service and nothing in their life can change and then we know they're not looking at the right metrics. 
 
Dr. Caroline West: 
A lot of people will be inspired to check out THIS WAY UP and to access your services. Can you take us through the cost of these services? 
 
Dr. Michael Millard: 
Most of what is on our website is free. So we have a little bit of a split model with our service. So we are a not-for-profit initiative with UNSW and St. Vincent's Public Hospital in Sydney. So I think about it as a medication. So if you were to go to the pharmacy and grab something off the shelf, there might be a fee, and if you were to have a prescription from your doctor, then it would be free. Now we have for some of our disorder specific courses, we have a fee. Now, the reason we have a fee is because we know that when someone is going to pay for something, they take it more seriously and they're more likely to get more out of it and they're more likely to complete it. Now, as I said, we've got two models. So if you, as a clinician prescribe one of our courses, they're all completely free. Now, what I love about this is that you're able to sit in your consulting room and you're able to look at your patient and say, "Here, there's a service called THIS WAY UP. It's an online treatment. I think it'll be really good for you. And because you're my patient and I'm looking after you, I'm going to prescribe it to you and it's actually going to be free." We know from the research that if clinicians recommend and prescribe something, people are also more likely to get a benefit from it and they're also more likely to complete it. So they're the dynamics that we're working with in terms of the THIS WAY UP programs. So all of what we do is designed to, I guess, encourage or prompt or help people to get the most out of the programs. That said, there's an enormous amount of resources on our website that's free. It's free to use as a clinician. One of the other things that I'm most proud of is we have a whole range of coping tools that we had translated into the 10 most common languages in New South Wales. So we looked around and we saw that a lot of translated material was just very basic psychoeducation around what is anxiety or what is depression and things like that. So we thought, well, why don't we take what people like to use and what they benefit from and we get them translated? And it's all there for you guys to use in your practice and put up in your waiting rooms in terms of problem solving, staying safe guides, all sorts of this. There's a whole range of stuff that I just encourage you to have a look at and integrate into your practice. 
 
Dr. Caroline West: 
And so, right at the beginning of this podcast, you mentioned how it's very hard to escape the news that psychological distress is on the rise, particularly in young Australians. We've outlined some of the treatment options, including medication in people who have a severe disorder that's affecting them and it may be appropriate. So that's not off the table, but there are so many other therapies that can be offered, including digital therapies. Do we also need to turn the focus to the things that keep us well? What could we be doing there that would actually help change the narrative? 
 
Dr. Michael Millard: 
Well, the whole narrative of mental health would benefit from a reframe to the idea that we should be empowering our patients, helping them to know that there are things that they can do now that will make a difference, a true difference in their lives. So many people, when you first come across them, that's the bit that's missing. And as a clinician, we have a responsibility often when people don't have that hope or that belief, firstly, to let them know that recovery is possible. And that part of recovery might be a whole, well, it will be a whole range of different things that we're going to help them to implement. So that's all the treatments that we've been talking about, the modifications that we've been talking about. 
And the aim really is to be building out their life as much as possible in terms of the things that keep us well. So that's the social connectedness. It's being engaged in community. It's looking after our bodies in a way where we have nourishment and show us and tell us that we're okay, and that what we're experiencing at this time will pass. 
 
Dr. Caroline West: 
Well, that's a very positive message to finish on. And I know that in our previous podcast, that people can listen to at our NPS MedicineWise website, we talked to two young people with lived experience, and they very much reiterated how important it was for them to have also a clinician that was focused on their strengths, their passions as well, what they were interested in doing with their lives, what they were looking forward to and how they wanted to manage their own health. We hear that word empowerment, and I know that it's possibly a word that gets bandied around a lot, but essentially that's what we're talking about here. 
 
Dr. Michael Millard: 
Absolutely. And really, I couldn't agree more about focusing on strengths because all young people have them and often they can't see them. And it's such a powerful thing to be able to help people along that journey, because we know that people are going to be interacting with the healthcare system throughout their lives, so we should be working to make their first experiences as good as possible and helping people to feel safe to do that. 
 
Dr. Caroline West: 
And on a personal note, you're a psychiatrist that works with young people. What has been particularly satisfying for you? 
 
Dr. Michael Millard: 
I guess it's following people and we see people at the worst point often, and then later we get to see them at the best point. And I think that being able to accompany people on that journey is an extraordinary gift. And I love to see the way that young people grow and blossom and find their confidence on their path, whatever that is going to be. 
 
Dr. Caroline West: 
Beautifully said. So thank you so much, Dr. Michael Millard for being with us today. Mike is a psychiatrist and also the director of THIS WAY UP. It's been fascinating exploring these frontiers of digital mental health services. Really the way of the future. A blend of options that are not only going to ... Well, obviously options include face-to-face, but these really are a definite shift in a different direction with digital approaches and they're becoming rapidly integrated. What you're saying is an extraordinary uptake in terms of clinicians and consumers. 
 
Dr. Michael Millard: 
Absolutely. It's been a pleasure. 

Dr. Caroline West: 
So thank you so much. And if anybody would like to find out more about THIS WAY UP, how would they do that, Mike? 
 
Dr. Michael Millard: 
Please, it's thiswayup.org.au. We love hearing from our service users, whether consumers or clinicians. Please yell out to us. Ask us questions, ask us concerns, send us complaints, send us compliments, we love it. So I look forward to hearing from you. 
 
Dr. Caroline West: 
And hopefully after this podcast, there'll be a flurry of activity. NPS MedicineWise at nps.org.au also has a fantastic hub for resources, for young people with mental health issues, for consumers and clinicians, helping you to find the right pathway for support. And if you'd like any information about CPD for this podcast, then please go to our website as well. Thank you very much for joining me today. I'm Dr. Caroline West. Bye for now.