reachout.com cohort study: a prospective follow-up study examining the role of online initiatives in...

ReachOut.com Cohort Study: A prospective follow-up study examining the role of online initiatives in promoting mental health literacy and early help-seeking Atari Metcalf 1,2, Lorraine Ivancic 1,2, Victoria Blake 1,2, Kerrie Buhagiar 1, Coralie Wilson 3, Sylvia Kauer4, Lena Sanci 4

1.ReachOut.com Australia2.Research Associate, Brain & Mind Research Institute, University of Sydney Medical School3. University of Wollongong4. University of Melbourne

Preliminary data

Please note that the findings reported in this presentation are based on preliminary data.

Project teamReachOut.com Australia Staff Academic Partners & Advisory

• Atari MetcalfPrincipal Investigator & Project Manager

• Deepika RatnaikeProject Executive

• Justin Farrell & Peter DanckwertsTechnical solution

• Kerrie BuhagiarSenior user, ReachOut.com Service

• Lorraine IvancicCo-investigator

• Victoria BlakeCo-investigator

• Dr Coralie Wilson Co-investigator, University of Wollongong

• A/Prof Lena Sanci Co-investigator, Melbourne University

• Dr Sylvia Kauer Co-investigator, Melbourne University

• Prof George Patton Advisor, Royal Children’s Hospital, Melbourne University

Supplier• Datalicious

Analytics data tracking

Why ReachOut exists

• Suicide is the leading cause of death in Australia for 15-24 yr olds1

• Mental ill health is the leading contributor to the burden of disease and injury (49%) among young Australians aged 15–242

• Half of all lifetime mental health problems start by the mid-teens and three quarters by the mid-20s3

• Median delay from onset to treatment is 10yrs4

• 1 in 4 young people (16-24yo) experience a mental health problem5

– 70% and 80% of young women and men respectively do not access any help5

– 86% of those who do not access help say they do not because they simply do not perceive any need for help5

• After family and friends, young people go online for support6

ReachOut’s emphasis on help-seeking

1. Recognise signs +

symptoms

2. Build skills to

express the need for

help

3. Increase knowledge

about sources of

help

4. Build positive attitudes

about seeking help

… and appraise whether … in a language that … and how to access … and the belief thatthey are experiencing can be understood these and what to appropriate treatmenta problem that might by others expect / support is effectiverequire intervention

FORMAL & INFORMAL HELP-SEEKINGSelf-help behaviours / social support / further clinical care

Key components of ReachOut Youth participation + UX research + clinical / gov’t / corporate partnerships

1Facts + personal

stories

2Moderated Online

Community

3Social marketing

4Education + Health settings

6Apps + tools

Targeted, audience focused, evidence based content disseminated across our platforms and syndicated through media and our partners.

Increased focus on media–rich and portable formats

Online peer to peer support to build social connections and reduce feelings of isolation and promote help-seeking.

Online outreach via other social utilities and sites; Yahoo! Answers

Awareness campaigns and social marketing initiatives that span online, social media, traditional media and place-based strategies.E.g. ‘There’s life after year 12 exams’ campaign

Sister website containing PD resources for teachers and professionals who work with young people in health, education and community settings

Feature our own (+ third party) apps and tools e.g.: ReachOut central (CBT game); WorkOut; Recharge Sleep App, WorryTime, Breathe, Smiling Mind (mindfulness meditation)

Study Aims• Explore how young people experiencing elevated symptoms of depression or anxiety engage with

ReachOut.com – an unstructured online intervention

• What happens after a young person uses ReachOut.com?– E.g. Do young people experiencing elevated symptoms of depression or anxiety, who are not otherwise

accessing mental health care, go on to seek appropriate help and/or adopt self-help strategies?

• What factors may predict prospective changes in help-seeking behavior and/or mental health literacy including:

– Use of specific website features – Level and frequency of engagement with the website, and – Demographic characteristics (age, gender, sexual orientation, cultural and educational background)

and/or level and type of mental health needs/symptoms

Focus of today’s presentation

Analysis of baseline characteristics of first wave of participants

• Socio-demographic characteristics• Mental health needs / status• Past / concurrent help-seeking behaviours• Mental health literacy and stigma• Future help-seeking intentions

Study design• Target sample of ~1,500 young people aged 16-25 recruited from ReachOut

• 4 surveys over 3 months, per participant:– Baseline (early during visit to ReachOut.com)– T2 at 1-week post first visit– T3 at 5-weeks post first visit– T4 at 3 months post first visit

• Semi-structured online interviews with a small sub-sample following T4

• Tag based ‘tracking’ technology to collect ReachOut.com usage data

Participant flow

Sees pop-up invitation on ReachOut Website

Clicks for more information

Consents participate (assigned ID)

Meets eligibility (aged 16-25, lives in

Australia) Completes baseline survey

Completes T2/T3/T4surveys

Invited to qualitative interview

Does not meet screening criteria

Does not consent

Declines invitation

SuperTag links survey ID to analytics ID for monitoring website engagement

+ Participants receive a $30AUD gift voucher for completing all 4 surveys (incentive is not mentioned until after they respond to the initial invite to reduce sampling bias)

Key measures at T1-T4What Baselin

e1 week 5 weeks 3 months

Purpose of visit to RO, past visiting history, how first heard of RO Y - - -

Demographics (age, gender, employment, education, cultural background, sexual orientation) Y Y - -

MH Symptoms (DASS-21), Suicidal ideation (specific SIQ critical items), Disability/Quality of Life (SF-12), Self-rated MH status

Y - Y Y

Perceived need for care Y - Y Y

Help-seeking intentions(GHSQ), Past help-seeking (including hospitalisation), Actual Help-seeking Behaviours (AHSQ) and Barriers to Help-seeking (BASH-B)

Y - Y Y

Mental health literacy (recognition, beliefs about causes, prevention, prognosis and treatment/sources of help)

Y - Y Y

Intention and confidence to assist/help others with mental health problems Y - Y Y

Stigma (includes measure of social distance) Y - Y Y

Exposure to other people experiencing MH problems and perceptions about their help-seeking experiences

Y - Y Y

Exposure to MH services, campaigns/media about mental health Y - Y Y

Impressions of RO, user experience, satisfaction and acceptability - Y - -

+ ongoing data collection of ReachOut engagement metrics+ semi-structured qualitative interview ~4 months post

Sample

Retention at follow up surveys (T2-T4)

T4 (3 months)

T3 (5 weeks)

T2 (1 week)

0 200 400 600 800 1000 1200 1400 1600 1800

822

1103

1419

1204

1505

1714

No. follow up invites sent vs completions

Invites Completes

RR: 68%

RR: 83%

RR: 73%

25%

75%

Follow up preference

SMS Email

Response rates calculated at August 20, 2015

Key characteristicsFirst time users aged 16-25 years

(43% of all study participants who have completed T1 & T2, N=573)

Demographics – first time usersGender RegionMale 15% Metro 71%

Female 82% Rural 29%

More options (non-binary) 4%

Age group Employment status16-17 33% Student 67%

18-20 29% Full time paid employment 12%

21-22 15% Paid casual employment 14%

23-25 23% Part time paid employment 10%

State Carer 3%

NSW 33% Volunteer work 7%

VIC 26% Unemployed 14%

QLD 17% Not employed & receiving sick allowance / disability / support pensions 2%

SA 8%

WA 10%

TAS 2%

NT 1%

ACT 3%

Base N: all new visitors aged 16-25 years at T2 (n = 573)

Cultural and linguistic diversity

Base for language & ATSI: all first time visitors aged 16-25 at T2 (571)

Cultural background %

Country of birth

Australia 86%

Other 14%

Both parents born in Australia 59%

English as the main language spoken at home 93%

Base for country of birth: all first time visitors aged 16-25 at T2 (573)

Aboriginal and/or Torres Strait Islander? %

No 96%

Yes, Aboriginal 3%

Yes, Torres Strait Islander 0%

Yes, both Aboriginal and Torres Strait Islander 0%

Don’t know 1%

Diversity in sexual orientation & education

72%5%

10%

6%7%

Sexual orientation

HeterosexualGay or lesbianBisexualUnsure or questioning

Primary school

Years 7-10

Years 11-12

Certificate or diploma

Undergrad

Postgrad

Don't know

No formal education

0% 10% 20% 30% 40% 50% 60%

0%

15%

55%

18%

9%

2%

1%

0%

Highest level of education achieved (%)

Base for sexual orientation: all first time visitors aged 16-25 at T2 (573)Base for education: all first time visitors aged 16-25 at T2 (573)

How and why do young people use RO?

Purpose of visiting ReachOut.com at first visit

0%

20%

40%

60%

80%

54%

9%15%

7%0%

10%3%

73%

21%

57%

10% 13%

56%

13%

Top reason Any rank

Base: all first time visitors aged 16-25 at T2 (517)

Main topic of information sought & how participants first heard about ReachOut

Depression

Anxiety

Abuse and violence

Helping others

Alcohol and other drugs

Mental health issues (general)

Self-esteem and confidence

Suicide

School/uni/study

Eating disorders

Other (< 3% or N~15)

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

18%

12%

5%

5%

4%

4%

3%

3%

3%

3%

40%

Briefly describe the main topic/s that you are looking for support/information on today (first response men-

tioned, thematic analysis)

Base: all first time visitors aged 16-25 at T2 (556 for main topic / 573 for how heard)

Online search

School

Media coverage (TV, radio, newspaper, magazine)

Another website

From a health professional

A friend

University

Can't remember

Other

0% 20% 40% 60%

57%

10%

7%

9%

5%

6%

3%

1%

4%

How did you first hear about ReachOut?

Mental health status

Most participants were experiencing symptoms of depression, anxiety and/or stress at baseline

Depression Anxiety Stress0%5%

10%15%20%25%30%35%40%45%

19%

26%

31%

9%11% 12%

16%12%

20%

14% 13%

21%

42%

37%

16%

DASS-21 Scores (%)

Normal Mild Moderate Severe Extremely severe

88% met the cut-off for mild or above symptoms for at least one MHD on DASS (12% had no symptoms)


Suicidal ideation at baseline

65%

35%

Recent thoughts of suicide: 2 or more thoughts in the last month (SIQ Sum Score of 4 or more on critical items – “moderate suicidal ideation”)

Recent thoughts of suicide No recent thoughts of suicide


28% reported severe suicidal

ideation(SIQ sum score of 15+ on

SIQ critical items – the equivalent of reporting the

presence of 3 different suicide thoughts in the past

week, including today – suggests the presence of severe suicidal ideation)

Self-assessed mental health

36%

34%

18%

9%4%

Overall, how would you rate your mental health, right now?

Poor Fair Good Very good Excellent

ALL0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45

30

25

Compared to the same time last year, would you say that your mental health is…

Worse About the same Better



Worse Better0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1022

4026

50 52

How much better or worse?

A little Some A lotBase: all first time visitors aged 16-25 at T2 (573)


Poor Fair Good Very good Excellent0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

9%

27%

44% 43%29%

23%

27%

28%

53%67%

68%

46%

28%

4% 5%

Compared to the same time last year, would you say that your mental health is…

Better About the same Worse


Past, concurrent + future help-seeking behaviours

Past help-seeking behaviours (lifetime)

70%

30%

Have you ever previously seen a mental health professional (e.g. a school coun-

sellor, counsellor, psychologist, psychia-trist or similar) to get help for personal

problems?

Yes

No

Psychologist

Counsellor

Psychiatrist

School counsellor

GP/doctor

Social worker

Youth worker

Other

0% 10% 20% 30% 40% 50% 60% 70%

66%

43%

26%

18%

6%

2%

1%

11%

What type of Mental Health Professional have you seen?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

12% 12% 26% 37% 13%

How helpful was the visit(s) to the MH pro-fessional?

Extremely unhelpful Unhelpful Neither Helpful Extremely helpful Base: all first time visitors aged 16-25 at T2 (Past help: 573 / Helpfulnessof MH professional: 402 / Type of MH Professional: 346)

15% had previously

been hospitalised for mental health

Recent/concurrent help-seeking behaviours

10%

26%

39%

25%

Have you had any stressful or serious problems in the last 3 MONTHS?

I have had few or no problems

I have had some problems but I did not feel I needed professional help

I have had some problems but I did not seek professional help al-though I thought I needed it

I have had some problems and I did seek professional help

Base: all first time visitors aged 16-25 at T2 (Any stressful problems: 573 / Use of help sources: 559)

FriendSearch engine

ParentPartner / boyfriend / girlfriend / spouse

Mental health professional (face to face)Doctor / GP

Other family memberMental health information websites

Have not sought help from anyone / anywhereOnline counselling services

Online discussion forumPhone helpline

Teacher / lecturerComplementary therapist

Religious leaderHave sought help from somewhere else not listed above

Online mental health coursesYouth centre

0% 10% 20% 30% 40% 50% 60% 70%

61%50%

45%40%

33%24%

21%20%

13%12%

10%9%

6%4%

3%3%3%

2%

Which of the following have you used in the past 3 MONTHS for a personal or emotional problem

Current help-seeking intentions

62%

38%

Are you currently experiencing a personal or emotional problem that you would like

help for?

Yes No

Base: all first time visitors aged 16-25 at T2 (Current problem: 573 / Future source of help: 336)

Family or partner

Psychologist

Unsure

Youth centre (ie Headspace)

Online counsellor

School counsellor

Phone counsellor

Teacher

University counsellor

Hospital

Emergency department

Mental health nurse

Guidance counsellor

Dietician

Colleagues/work

Pet

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0%

18.8%18.2%

17.3%16.1%

12.5%8.6%

6.5%6.2%

6.0%5.7%

4.8%3.9%3.9%

2.7%2.1%

1.5%1.5%

1.2%0.9%0.9%

0.6%0.6%

0.3%0.3%0.3%0.3%0.3%0.3%0.3%0.3%0.3%

Who or where are you most likely to go for help with your problem?

Current help-seeking intentions x suicidal ideation


Who or where are you most likely to go for help with your problem?

No recent thoughts of suicide(N=215)

Moderate suicidal ideation (SIQ sum score 4+ on critical items; N=245)

Severe suicidal ideation (SIQ sum score 15+ on critical items; N=121)

Friends * 26% 15% 16%

Family or partner * 26% 16% 11%

Psychologist 18% 17% 13%

GP/Doctor 14% 17% 17%

Counsellor * 7% 5% 1%

School counsellor * 7% 4% 3%

Youth centre (i.e. Headspace) 7% 7% 6%

Online counsellor ** 7% 6% 10%

Phone counsellor 6% 3% 6%

Nowhere / no-one ** 6% 10% 13%

Psychiatrist 2% 5% 5%

Barriers to seeking help


* I'd never want my family to know I was getting professional help

* I could not afford to get professional help even if I wanted to

If i had a problem I would solve it myself

I think I should work out my own problems

* If I got professional help i may have to do or say something I don't want to

Even if I had a problem, I'd be too embarrassed to get professional help for it

* If I got professional help, I might found out I was crazy

Older adults really can't understand the problems that young people have

* Even if I wanted to, I wouldn't have time to get professional help

0% 10% 20% 30% 40% 50% 60% 70% 80%

31%

25%

75%

44%

29%

30%

9%

25%

19%

49%

54%

65%

59%

58%

42%

38%

38%

33%

% of respondents agreeing or strongly agreeing with each statement x DASS Score

Mild or above 1+ DASS Normal DASS

* indicates statements where young people with mild or above DASS scores on one or more categories were significantly more likely to agree with this option on chi-square tests

MH literacy & stigma

Mental health literacy – ability to correctly identify mental health problems from vignettes


Vignette presented % shown for RO users and 2011 National survey of MH Literacy and Stigma (in brackets)

Top categories mentioned Psychosis * (N=3)Depression with suicidal

thoughts (N=17)

Depression with

substance misuse (N=24)

Depression (N=221)

PTSD (N=35)

Social Phobia (N=243)

Depression 0% (33%) 71% (84%) 88% (77%) 81% (74%) 0% (16%) 4% (16%)

Anxiety / anxious 33% 12% 8% 10% 17% 76%

Social anxiety / phobia 0% 0% 0% 0% 0% 44%

PTSD 0% 0% 0% 1% 74% 0%

Low self-esteem / confidence 0% 0% 0% 0% 3% 7%

Trauma 0% 0% 0% 0% 9% 0%

Stress 33% 6% 13% 7% 3% 1%

Percentage of respondents mentioning each category to describe the problem shown in the vignette (multiple categories allowed; sum >100%)

Stigma (personal views)


Perso

n cou

ld snap o

ut of th

is pro

blem

If I ha

d this

proble

m I wou

ldn’t te

ll any

one

Problem is

a sign

of per

sonal

weakn

ess

Problem is

not a re

al medic

al illn

ess

People

with

this

proble

m are da

nger

ous

People

with

this

proble

m are un

predic

table

Avoid

peop

le with

this

prob

lem

0%

10%

20%

30%

40%

6%

29%

7%3% 5%

17%

1%8%

24%

8%12% 12%

28%

8%6%

39%

6%11% 11%

6%

25% 25% 25%

6%

26%

6% 6% 4%10%

26%

3% 3%11%

Percentage of respondents who ‘agree’ or ‘strongly agree’ with statements about personal attitudes to mental disorders

Depression Depression with substance misuse Depression with suicidePsychosis PTSD Social phobia

Stigma (perceived social views)


0%

20%

40%

60%

80% 69%56%

66% 64%

38%57%

46%

68%

24%

52%64%

44%

64%52%

78%

44%61% 67%

33%

61%50%50% 50% 50% 50%

75% 75%

50%61% 55% 52%

63%50%

61%45%

64% 54%67% 69%

31%46% 41%

Percentage of respondents who ‘agree’ or ‘strongly agree’ with statements about perceived attitudes to mental disorders

Depression Depression with substance misuse Depression with suicidePsychosis PTSD Social phobia

Conclusions, limitations and next steps

Conclusions

• ReachOut engages young people with very high severity symptoms of depression, anxiety, stress and suicidal ideation

– possibly early in onset (given self-reported changes in mental health over past 12-months)– raises strategic questions about alignment to the program target group

• The majority of young people accessing RO (70%) have previously sought professional help at sometime in their lifetime, but overall:

– very few report recent/concurrent help-seeking from professional sources (25% in past 3-months). – very few report intending to seek help from professional sources for their current problem, but an openness

toward seeking support from social / informal sources (family, friends etc)– help-seeking intentions in those with moderate and severe suicidal ideation appear consistent

with help-negation effect observed in other studies (i.e. higher suicidal ideation = higher likelihood to report preference to seek help from no-one or nowhere)

• RO users show comparable levels of MH literacy but slightly higher levels of personal and perceived stigma views to those observed in general Australian youth population surveys

Limitations + next steps

Limitations• Further analysis needed to understand differences in help-seeking histories

between users with and without symptoms of depression, anxiety or stress, or suicide

• Pre/post design makes intervention attribution difficult

Next steps• Finalise recruitment and follow-up (early 2016)• Examine any changes in mental health literacy, stigma, help-seeking

intentions & behaviour over time – model for variation in program usage/dosage, symptoms, socio-demographic characteristics

reachout.com cohort study: a prospective follow-up study examining the role of online initiatives in...

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