Tele-mental health is a promising solution to Indonesia’s scarcity of qualified mental health professionals
Indonesia has far more people in mental distress than its mental health professionals are able to treat, presenting a tremendous challenge in delivering mental health services to everyone who needs them. The World Health Organisation has called this the mental health gap, which is defined as the percentage of individuals with mental health conditions who do not receive the treatment they need. This mental health gap is not unique to Indonesia. Many middle- and lower-income countries face the same problem, but the exact details vary from place to place. Each country requires, therefore, a different approach to reducing the treatment gap.
But first, what do we know about mental health in Indonesia? The Indonesian archipelago consists of five large islands and thousands of smaller ones. In Indonesia there is not only a limited number of mental health professionals; accessibility is a problem as well. The majority of mental health professionals work in the major urban centres. Access to mental health services is therefore difficult in rural and remote areas. Indonesia faces a large challenge in distributing mental health services equally across the country.
Discussions about accessibility should include thinking about the medium and methods of delivery. The most common medium for providing mental health services is face-to-face contact in a consultation room. However, tele-mental health is also widely used, in various contexts, and should be taken into consideration when thinking about ways to increase access. Tele-mental health is defined as mental health services that are delivered through digital mediums. One such medium is the internet. But can mental health services really be provided via computers and smartphones?
Up until 2017, no study on tele-mental health had been conducted in Indonesia despite a significant increase in internet usage across the country during the preceding decade. Using the internet to deliver mental health services is promising because it can overcome the complications posed by long distances. However, we first need to ask whether Indonesians are at all interested in accessing tele-mental health. A survey ascertaining the acceptability of online mental health interventions, specifically for depression, demonstrated that a majority of participants were indeed open to tele-mental health delivered over the internet. Participants indicated that they would like to try such services if they were available in Indonesia (73.7 per cent approval), whether these services were used as a substitute for (73.3 per cent) or as a supplement to (73 per cent) face-to-face interventions. Clearly, there is an interest in tele-mental health in Indonesia.
Many participants appreciated the simplicity and privacy of tele-mental health; they would not need to go to a clinic or a hospital – let alone a mental hospital – to receive treatment.
The first study
Since no research on tele-mental health had been conducted in Indonesia so far, we started a study of online interventions in behavioural activation in Indonesia in 2017. Our study specifically targeted depression, which is one of the most common mental health problems worldwide. The aim of behavioural activation is to increase patients’ engagement in pleasurable activities, which in many cases will improve their mood. We developed a web-based program for this type of intervention. It consists of eight modules with step-by-step instructions for each. These instructions allow individuals to participate in the program independently. However, we also provided human support to keep all participants on track by checking in every week and discussing their progress in each module. We also answered their questions if they encountered any difficulties in accessing or completing the program.
To provide human support we trained several lay people in how to support the participants when they accessed the intervention program online. All support was provided online; there was no face-to-face contact. We dubbed these assistants ‘lay counsellors’, and they were supervised by licensed clinical psychologists. The results demonstrate that online behavioural activation is effective in reducing depression in Indonesian sample populations. This is good news. This result shows that tele-mental health delivered through internet has a promising future in Indonesia. But that is not all. We also gained other useful insights into how the internet might support tele-mental health.
An important part of the mental health gap is the problem of limited human resources, which is why task sharing is worthy of serious consideration. Task sharing is a means to overcome the scarcity of mental health professionals by delegating specific tasks to non-professionals, but only under the condition that they are appropriately trained to deliver basic support for specific mental health issues.
We made use of task sharing in our study and it worked very well. It would be interesting to see if this approach can also be used in primary care, such as in the community health centres and hospitals, to manage mental health problems throughout Indonesia. Our study has demonstrated that task sharing can be done from afar and via the internet. To develop sustainable tele-mental health initiatives, task sharing systems will be necessary.
Moreover, computer programs or smartphone apps can be used to deliver information or to support self-help activities. In our study we learned that some participants accessed the intervention program independently and without seeking support from lay counsellors. This might be, as mentioned above, because our online program provided clear step-by-step instructions. For some people, this was all they needed and no human support was necessary. However, human support was necessary for several participants, especially in the more complicated modules.
To a certain extent, the internet itself can be part of the task sharing system. Online programs can be used without human support to deliver information about mental health issues for psycho-educational purposes. Moreover, information about self-help interventions can be provided with clear step-by-step instructions. This is an important part of tele-mental health and can be helpful when presented in the right way.
We conclude that tele-mental health delivered over the internet constitutes a promising approach for reducing the mental health gap in Indonesia. However, we need to pay attention to several important issues before proceeding further. Tele-mental health might appear ‘alien’ to some people, and especially to those who do not use the internet every day. A campaign informing people about tele-mental health to address such issues, along with improvements in Indonesia’s online infrastructure, will need to be undertaken. Ethical issues need to be considered as well. Tele-mental health is relatively new compared to regular, face-to-face mental health services. All ethical discussions so far in regard to mental health services have assumed face-to-face delivery, so these discussions will need to be revisited when it comes to tele-mental health. At the very least, it is important to inform clients, counsellors, psychologists and therapists about the differences between regular mental health services and tele-mental health services, and to make them aware of the potential risks.
Retha Arjadi (firstname.lastname@example.org) is a lecturer at Atma Jaya Catholic University of Indonesia in Jakarta. She received her PhD in 2018 from the University of Groningen for her research on the effectiveness of an internet-based intervention for depression.